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Introduction 

General  Environment 

Sanitation 


Part  One 


Cleveland     Hospijtal  'afivd 
Health     Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital*Counctl 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -  Ohio 


Pref 


reiace 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the  work 
and  through  whose  hands  this  report  has  been  received  for  publication 
consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman 

Mrs.  Alfred  A.  Brewster 

Thomas  Couhlin 

Richard  F.  Grant 

Samuel  H.  Halle 

Otto  Miller 

Dr.  H.  L.  Rockwood 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were : 
Director — Haven  Emerson,  M.  D. 
Assistant-Director — Gertrude  E.  Sturges,  M.  D. 

Cleveland  Division  of  Health — 

Study  in  charge  of  Haven  Emerson,  M.  D. 

[W.  G.  Moorehouse,  M.  D. 
Assisted  by  \G.  B.  Gascoigne 

\l.    S.    OSBORN 

Consultant  in  Orthopedics — Robert  B.  Osgood,  M.  D. 

Hospitals  and  Dispensaries  in  Cleveland — 

Study  in  charge  of  Michael  M.  Davis,  Jr.,  Ph.  D. 

(Anna  M.  Richardson,  M.  D. 
Mrs.  Mary  Strong  Burns,  R.  N. 
[Miss  H.  L.  Leete,  R.  N. 

Consultant  in  Hospital  Administration — W.  L.  Babcock,  M.  D. 
Consultant  in  Convalescent  Care — Frederic  Brush,  M.  D. 

Nursing  in  Cleveland — 

Study  in  charge  of  Miss  Josephine  Goldmark,  B.  A. 

'Miss  Anne  Strong,  R.  N. 
Mrs.  Alice  F.  Piggott,  R.  N. 
Assisted  by  I  Miss  Elizabeth  Fox,  R.  N. 

]  Miss  Janet  M.  Geister,  R.  N. 
Miss  A.  H.  Turner,  A.  B. 
(Mrs.  Anna  Staebler,  R.  N. 


Industry  in  Cleveland — 

Study  in  charge  of  Wade  Wright,  M.  D. 

Assisted  by  /Mrs.  Marie  Wright 

"i  Miss  Florence  V.  Ball 

Venereal  Disease  in  Cleveland — 

Study  in  charge  of  W.  F.  Snow,  M.  D. 

/-Alec  Thomson,  M.  D. 
Assisted  by  j  Allison  French 

\  Mrs.  M.  P.  Falconer 
[Bascomb  Johnson 

Child  Health  Work  in  Cleveland — 

Consultant  in  Child  Health — S.  Josephine  Baker,  M.  D.,  D.  P.  H. 
In  charge  of  Sanitary  Survey  of  Children's  Institutions — 
Henry  G.  Mac  Adam,  M.  D. 

Tuberculosis  in  Cleveland — 

Study  in  charge  of  Donald  B.  Armstrong,  M.  D. 

Mental  Hygiene  in  Cleveland — 

Study  in  charge  of  Thomas  W.  Salmon,  M.  D. 

Assisted  by  Jesse  M.  W.  Scott,  M.  D. 

Vital  Statistics  in  Cleveland — 

Study  in  charge  of  Louis  I.  Dublin,  Ph.  D. 
Pharmacy  in  Cleveland — 

Study  made  by       Edward  Spease,  B.  S. 

The  entire  staff  is  under  obligation  to  Miss  Elizabeth  R.  Cummer  and 
Miss  Josephine  Colegrove  for  secretarial  work  in  assembling  and  pre- 
paring reports  on  individual  hospitals,  in  proof-reading  and  in  indexing  the 
completed  report. 

Bibliography  of  Surveys  prepared  by  Miss  Julia  T.  Emerson. 
Publicity  for  the  Survey  in  Cleveland — 
In  charge  of  Carlton  Matson 
Assisted  by  Miss  Georgia  Bowen 
Special  Reports  were  contributed  by — 

National    Committee    for    the    Prevention    of    Blindness. 

Mrs.  Winifred  Hathaway,  Executive  Secretary. 
American  Society  for  the  Control  of  Cancer. 

F.  J.  Osborne,  Executive  Secretary. 
Association  for  the  Prevention  and  Relief  of  Heart  Disease. 
Miss  M.  E.  Woughter,  Executive  Secretary. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have  been 
met  by  appropriations  received  from  the  Community  Chest  through  the 
Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole  or  by  sections  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


Letters 
of 
Transmittal 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clevelandhospitaOOclev 


Letters  of  Transmittal 

To  the  Cleveland  Hospital  Council: 

There  is  presented  herewith  the  report  of  the  Committee  on  the  Hospital 
and  Health  Survey  of  Cleveland,  appointed  on  October  1,  1919,  as  recorded 
in  the  minutes  of  the  Cleveland  Hospital  Council: 

"Moved  by  Mr.  Anisfield: 

"That  the  action  of  the  President  of  the  Cleveland  Hospital  Council  in 
appointing  a  committee  consisting  of  the  following  persons:  Malcolm  L. 
McBride,  Chairman;  Otto  Miller,  Richard  Grant,  Dr.  H.  L.  Rockwood, 
Thomas  L.  Coughlin,  Samuel  H.  Halle  and  Mrs.  A.  A.  Brewster,  to  conduct 
a  health  survey  of  the  City  of  Cleveland,  be  ratified  and  endorsed,  and  that 
the  general  outline  of  the  Hospital  and  Health  Survey  as  prepared  by  Mr. 
Wright  and  attached  hereto  be  used  as  a  guide  by  the  committee  in  conduc- 
tion of  the  Survey,  which  outline  shall  be  subject  to  modification  as  may 
be  needed. 

"The  Committee  will  have  full  power  in  the  premises  to  engage  per- 
sonnel and  proceed  with  the  Survey.  It  is  emphasized  that  there  should  be 
specific  and  definite  recommendations  regarding  the  building  programs  and 
the  character  of  the  future  work  of  the  existing  hospitals,  such  recommenda- 
tions to  be  made  at  as  early  a  date  as  possible. 

"Throughout  the  whole  investigation  the  committee  is  asked  to  be  as 
specific  as  possible  in  its  recommendations. 

"Seconded  by  Mr.  Hildreth  and  carried  unanimously." 


GENERAL  OUTLINE 

For  Hospital  and  Health  Survey 

Hospital  and  health  activities  have  a  common  purpose. 
It  is  better  public  health  and  fewer  preventable  deaths.     There  are  four 
fundamental  contributing  factors  to  the  efficient  work  of  all  hospital  and 
health  organizations  working  to  this  end. 
These  are: 

Development  of  medical  education,  both  post  graduate  and 

under  graduate. 
Development  of  nursing  education,  both  general  and  special. 
Advancement  of  public  health  and  preventive  medicine. 
Care  of  the  individual  sick. 
Due  consideration  must  be  given  to  each  of  these  four  factors  in  con- 
sidering the  work  of  any  individual  hospital  or  health  organization  or  group 
of  such  organizations  or  community  hospital  or  health  needs. 
The  work  of  this  committee  may  be  divided  into  two  parts: 

I.  A  survey  and  study  of  the  existing  hospital  and  health  activities — public  or  pri- 
vate— of  Cleveland.  It  should  determine  the  contribution  which  is  now  being  made  to 
the  common  end  by  the  different  institutions  individually  and  collectively,  discover  ways 
in  which  these  institutions  may  be  made  to  contribute  more  by  reasonable  changes  either 


8  Hospital  and  Health  Survey 


in  the  division  of  labor  with  other  institutions,  the  volume  of  work  done  or  contemplated, 
or  in  the  way  of  doing  work.     This  involves  a  survey  and  study  of: 

1.  Medical  education  in  Cleveland  as  at  present  conducted. 

(a)  Use  of  clinical  material  and  facilities  in  Cleveland  by  the  Medical 
School  for  under-graduate  instruction,  for  post-graduate  instruc- 
tion of  young  medical  men,  for  instruction  and  development  of 
the  medical  profession  in  general. 

2.  A  study  of  nursing  education  as  conducted  at  present  in  Cleveland. 

(a)  Training  Schools  giving  general  nursing  education. 

(b)  Facilities  for  providing  nurses  with  special  education  and  training. 

3.  The  Division  of  Health  of  the  City  of  Cleveland  and  its  relation  to  the 
hospitals,  dispensaries  and  other  medical  institutions  and  the  profession  in 
general.  Its  activities  in  the  care  of  contagious  diseases  and  in  preven- 
tive medicine. 

4.  A  study  of  the  existing  hospitals  and  their  plans  for  extension  to  determine: 

(a)  The  available  and  contemplated  facilities  for — 

Pay  or  private  room  patients, 
Part-pay  and  ward  patients, 
Free  patients. 

(b)  The  probable  normal  needs  of  the  community  for  each  of  these 
classes  of  accommodations. 

5.  A  study  to  determine  the  present  and  contemplated  facilities  as  well  as 
the  probable  normal  needs  of  the  city  for  the  care  of  certain  classes  of  sick: 

Contagious,  including  venereal  diseases, 

Acute  surgical, 

Acute  medical, 

Chronic  surgical  and  orthopedic, 

Chronic  medical, 

Convalescent, 

The  immediate  development  of  facilities  for  chronic  and  con- 
valescent patients  as  a  means  of  saving  hospital  space. 
Insane  and  mental  diseases, 
Aged  and  infirm, 
Maternity, 
Babies  and  children, 
Accident  and  emergency. 

6.  Dispensaries.  A  study  of  their  location  as  to  their  availability  to  all 
Cleveland  citizens  in  need ;  the  type  of  cases  receiving  treatment  therein ; 
the  facilities  of  the  various  dispensaries  to  do  properly  theVork  undertaken. 

II.  The  second  part  is  a  more  extended  study  of  the  community  to  determine  the 
ideal  number,  grouping,  location,  character  and  functions  of  the  hospital,  medical  and 
health  institutions  which  can  best  serve  Cleveland  at  present  and  during  the  reasonable 
future  development  of  the  city.     This  entails  the  following: 


Letters  of  Transmittal 


1.  Morbidity,  accident  and  mortality  rates  for  the  city,  as  a  whole,  and  by  dis- 
tricts, based  on  city  statistics,  questionnaires  to  doctors,  hospital  and 
dispensary  records,  Industrial  Commission  reports,  U.  S.  Census  figures  on 
occupations,  races  and  ages  and  morbidity  census  in  other  cities,  per- 
haps house-to-house  canvass  of  selected  districts  to  learn  amount  of  sick- 
ness, total  and  classified. 

2.  Care  secured  by  the  sick,  economic  ability  to  secure  care.  Home  condi- 
tions affecting  care.  Knowledge  or  ignorance  of  existing  facilities.  Efforts 
of  agencies  to  reach  those  needing  their  care.  Constituencies  of  various 
hospitals  or  attraction  of  hospitals  for  various  groups.  Survey  of  ade- 
quacy of  home  care  in  typical  neighborhoods. 

3.  Capacities  and  facilities  of  existing  agencies  for  giving  the  amount  of 
remedial  care  shown  to  be  needed  by  studies  of  the  amount  and  present 
care  of  all  sickness,  accidents,  and  by  prospective  increase  of  population. 

4.  The  estimated  reduction  in  sickness  from  extension  of  preventive  medicine 
and  health  insurance,  based  on  European  experiences. 

5.  The  Medical  School's  relation  to  present  and  future  hospitals,  dispensaries, 
sickness  prevention  and  the  health  department. 

6.  The  relation  of  nursing  training  schools  to  present  and  future  hospitals, 
dispensaries,  sickness  prevention  and  the  health  department. 

On  October  3,  1919,  arrangements  were  made  to  undertake  the  study  as 
proposed  in  the  communication  appointing  this  committee. 

The  Survey  staff  was  organized  and  began  its  work  in  Cleveland  on 
November  9,  1919.  The  field  studies,  the  public  meetings  and  the  con- 
ferences with  representatives  of  the  organizations  and  agencies,  both  public 
and  private,  concerned  with  the  various  aspects  of  the  field  of  inquiry  were 
completed  early  in  July,  1920. 

The  accompanying  text,  now  printed  and  available  for  distribution,  has 
been  passed  upon  and  approved  by  the  committee. 

The  subjects  treated  of  include  those  specified  at  the  time  the  committee 
was  appointed  and  several  others  which  it  seemed  desirable  to  add  during 
the  progress  of  the  studies. 

It  is  recommended  that  the  Cleveland  Hospital  Council  use  its  influence 
in  support  of  the  proposals  and  conclusions  of  the  report. 

Your  committee  requests  its  discharge  with  the  completion  of  the  serv- 
ices expected  of  it. 

(Signed)  Malcolm  L.  McBride,  Chairman, 
Mrs.  Alfred  A.  Brewster, 
Thomas  Coughlin, 
Richard  F.  Grant, 
Samuel  H.  Halle, 
Otto  Miller, 
Dr.  H.  L.  Rockwood, 
Howell  Wright,  Secretary. 
Cleveland,  Ohio,  September,  1920. 


10  Hospital  and  Health  Survey 

To  the  Hospital  and  Health  Survey  Committee 
of  the  Cleveland  Hospital  Council  : 

Sirs: 

There  is  herewith  presented  to  you  in  its  completed  form  and  prepared 
for  publication  the  report  of  the  several  members  of  the  Survey  staff  who 
have,  under  my  direction,  and  with  your  approval,  studied  the  Hospital 
Service,  Education  in  the  Medical  and  Allied  Professions,  and  the  Facilities 
for  Health  Protection  in  Cleveland. 

At  the  risk  of  criticism  for  failure  to  seize  the  opportunities  presented  to 
obtain  and  report  all  possible  facts  bearing  upon  the  care  of  the  sick  and 
the  protection  or  development  of  health,  only  such  material  has  been  collected 
and  only  such  portions  of  the  collected  data  have  been  prepared  for  publi- 
cation as  appeared  to  contribute  substantial  force  to  the  discussion  of  the 
problems  and  to  the  recommendations  arrived  at. 

Wherever  information  reliable  in  source  and  for  all  practical  purposes 
comparable  to  what  would  be  found  in  Cleveland  was  known  of,  it  was 
accepted  and  used  without  attempt  at  duplication  or  repetition. 

From  the  beginning  of  our  studies  all  of  the  investigators  and  consultants 
engaged  in  the  work  have  acted  upon  the  assumption  that  personal  discus- 
sion, argument,  demonstration  and  persuasion  upon  the  spot  with  those 
directly  concerned  with  administration  or  service  in  the  health  or  hospital 
field,  was  sure  to  contribute  more  to  change  in  method  or  improvement  in 
results  than  could  be  expected  from  the  reading  of  the  printed  page  at  a 
later  date. 

There  have  been  no  pains  spared  to  insure  a  broad  and  intimate  contact 
with  all  groups  of  citizens  concerned  in  any  way  in  the  multitude  of  services 
comprised  in  the  hospital  and  health  problem. 

Recognizing  that  Cleveland  has  been  a  generous  contributor  to  each  of 
the  national  movements  now  engaged  in  attacking  the  causes  of  ill  health 
and  in  spreading  knowledge  of  self-protection  against  disease  and  disability, 
it  seemed  reasonable  to  expect  in  return  collaboration  by  these  same  national 
groups  in  Cleveland's  effort  at  self-analysis  and  a  share  in  the  responsibility 
and  privilege  for  providing  a  plan  and  program  for  so  typical  and  aggressive 
an  American  municipality.  Either  through  direct  assumption  of  the  entire 
cost  of  services  obtained,  or  by  sharing  the  cost  of  officers  temporarily  as- 
signed to  the  Cleveland  Survey,  or  through  the  generous  gift  of  time  and 
attention  at  no  expense  to  the  Survey,  we  have  been  so  fortunate  as  to  obtain 
for  incorporation  into  our  report  the  studies  and  conclusions  of  representa- 
tives of: 

The  National  Tuberculosis  Association, 
The  American  Social  Hygiene  Association, 
The  National  Committee  for  Mental  Hygiene, 
The  National  Committee  for  the  Control  of  Cancer, 
The  Society  for  the  Prevention  and  Relief  of  Heart  Disease, 
The  National  Committee  for  the  Prevention  of  Blindness, 
The  National  Committee  for  Study  of  Public  Health  Nursing 
Education.  . 


Letters  of  Transmittal  11 

The  American  College  of  Surgeons. 
Our  investigators  have  been  drawn  also  from  the 
Harvard  School  of  Industrial  Hygiene, 
Boston  Dispensary, 

New  York  City  Department  of  Health, 
American  Red  Cross, 
American  Child  Hygiene  Association. 

From  Cleveland  itself  we  have  obtained  continuous,  helpful  and  devoted 
service,  not  only  from  those  whose  occupations,  professional  and  lay,  placed 
them  in  a  position  to  assist  or  contribute  to  the  volume  and  success  of  our 
study,  but  from  that  great  group  of  well  informed  men  and  women  who  are  ready 
to  devote  their  time  and  capacities  to  any  undertaking  which  offers  assurance 
of  improvement  in  the  conditions  of  life  of  their  fellow  citizens.  Among  the 
most  important  sources  of  assistance  have  been  the  officers  of  the  Division 
of  Health,  the  Board  of  Education,  the  Welfare  Federation,  the  Academy 
of  Medicine,  Western  Reserve  University,  the  Central  Nursing  Committee, 
the  Visiting  Nurse  Association,  the  Associated  Charities,  the  Consumers' 
League,  Y.  W.  C.  A.,  the  Junior  League  and  the  Women's  City  Club. 

During  the  course  of  the  Survey  there  was  gj-mortunity  to  supplement 
and  cooperate  with:  Y 

(a)  A  special  committee  on  Social  Hygiene  whose  work  was  drawing 
to  a  close  about  the  time  this  Survey  was  begun. 

(b)  The  Welfare  Federation,  which  undertook  a  study  of  the  social, 
educational  and  recreational  functions  of  the  institutions  for  children,  while 
the  Survey  analyzed  the  sanitary,  medical  and  health  services  provided. 

(c)  The  Consumers' League  in  its  study  of  the  use  of  milk  in  Cleveland 
and  in  its  recently  inaugurated  study  of  the  employment  of  children. 

In  submitting  this  report  it  is  a  pleasure  to  pay  tribute  to  the  breadth  of 
vision  and  the  public  spirit  shown  in  the  objectives  which  the  Cleveland 
Hospital  Council  set  before  you,  its  committee,  for  accomplishment.  It 
seems  reasonable  to  expect  that  such  benefits  as  may  accrue  to  Cleveland 
from  the  study  of  the  local  situation  are  not  to  be  confined  to  this  city  alone, 
but  will  stimulate  similar  studies  elsewhere  and  will  prove  of  practical  value 
to  that  large  group  of  executives,  trustees  and  their  financial  supporters 
throughout  the  country,  who  are  carrying  the  responsibility  for  health  de- 
velopment and  its  protection,  for  disease  prevention  and  its  treatment,  for 
education  in  the  field  of  medical  services. 

For  the  support,  encouragement  and  critical  judgment  of  the  committee 
I  wish  to  express  the  gratitude  of  those  engaged  upon  the  Survey.  There 
have  been  offered  to  us  full  freedom  of  opportunity  and  a  spirit  of  coopera- 
tion and  helpfulness  without  which  our  friendly  contact  with  the  institu- 
tions, agencies  and  branches  of  the  civil  government  would  have  been  diffi- 
cult to  obtain. 

It  must  be  apparent  that  in  no  single  subject  of  our  report  has  the  field 
of  study  been  exhausted.  Our  conclusions  may  well  be  modified  in  the 
future  by  what  we  trust  will  be  undertaken  in  the  way  of  further  self -analysis 


12  Hospital  and  Health  Survey 

and  research  in  the  methods  and  results  of  medical  social  service  which  now- 
adays fills  so  important  and  costly  a  function  in  the  structure  of  community 
life,  safety  and  progress. 

The  cost  of  the  Survey  has  come  within  the  amount  originally  set  aside 
for  this  purpose:  namely,  $53,000,  of  which  $3,000  had  been  spent  on  a 
study  and  report  of  social  conditions  which  contribute  to  venereal  disease 
incidence  before  the  general  plan  of  the  hospital  and  health  study  was  com- 
pleted. The  total  cost  of  the  Survey,  estimated  at  the  time  of  going  to  press, 
including  publicity  service  and  publication  of  the  report,  has  been  $52,668.98, 
under  the  following  functional  headings : 

Direction  and  Administration $24,902.38 

Tuberculosis 938.63 

Hospital  and  Dispensary..... 5,117.54 

Child  Hygiene 1,026.27 

Statistical _ 562.00 

Venereal  Disease 3,586.04 

Nursing _ _ 3,829.85 

Mental  Disease  and  Mental  Deficiency 385.00 

Industrial  Hygiene...- 4,429.68 

Children's  Institutions ._ 891.59 

Publication 7,000.00 

Total ...-. ...$52,668.98 

In  addition  to  the  services  paid  for  under  the  above  headings  there  have 
been  contributed,  as  indicated  previously,  the  services  of  the  representatives 
of  a  number  of  the  national  and  local  organizations  interested  in  some  aspect 
of  health  protection.  It  would  have  been  impracticable  to  engage  and  pay 
for  those  directing  and  participating  in  these  contributed  services,  but  the 
following  statement  gives  a  very  conservative  estimate  of  the  financial 
burden  which  has  been  borne  by  these  organizations  in  the  interest  of  the 
Survey  of  Cleveland: 

National  Committee  on  Mental  Hygiene _ $3,813.52 

Committee  for  Study  of  Public  Health  Nursing  Education 2,210.00 

American  Social  Hygiene  Association 1,500.00 

The  Welfare  Federation,  Cleveland 1,400.00 

The  Consumers'  League  of  Ohio 800.00 

American  Red  Cross  Bureau  of  Public  Health  Nursing 250.00 

American  Society  for  Control  of  Cancer 100.00 

National  Society  for  the  Prevention  of  Blindness 100.00 

Association  for  Prevention  and  Relief  of  Heart  Disease. 100.00 


$10,273.52 


Owing  to  the  fact  that  the  work  of  the  Survey  has  extended  over  a  con- 
siderable period  of  time,  and  since  continuous  progress  in  the  development 
of  services  for  the  sick  and  facilities  for  disease  prevention  has  occurred  in 
Cleveland  during  the  period  of  our  study,  it  will  be  found  that  the  present 


Letters  of  Transmittal  13 

report,  consisting  as  it  does  of  contributions  made  by  investigators  at  dif- 
ferent periods  of  time  between  November,  1919,  and  July,  1920,  does  not  in 
all  respects  describe  the  conditions  as  they  are  on  the  date'  of  publication. 
Furthermore,  it  will  be  a  matter  of  satisfaction  to  you,  as  well  as  a  matter  of 
interest  to  the  reader,  to  know  that  many  of  the  recommendations  which 
are  proposed  in  the  various  chapters  of  our  report  have  already  been  adopted. 
It  has  been  a  privilege  to  be  associated  with  the  investigators  who  have 
shared  the  work  and  to  have  played  the  part  of  coordinator  in  the  under- 
taking. 

Respectfully  submitted  by 

Haven  Emerson,  M.  D.,  Director. 

Cleveland,  Ohio, 

Hospital  and  Health  Survey, 

September  22,  1920. 


Table   of   Contents 


PART  I. 

Introduction — General  Environment,  Sanitation 

I.  Introduction  Page 

General  Remarks  on  Report _ 25 

Summary  of  Parts  of  Report 28 

Summary  of  Recommendations  of  Report 35 

II.  Environment  and  Sanitation 

Population  and  Area.- 39 

Topography  and  Climate „ 46 

Housing 48 

Water  Supply 57 

Sewage  Disposal , 60 

Street  Cleaning  and  the  Collection  and  Disposal  of  Garbage  and  Refuse....  67 

Flies  and  Mosquitoes - 83 

Smoke  and  Its  Prevention ___ _ 85 


PART  II. 

Health  Services 

I.  Introduction ;. .. 103 

II.  Public  Health  Services 

Division  of  Health^ — 

Administration 110 

Bureaus 1 .. 122 

New  Activities  Proposed..... 1 73 

III.  Private  Health  Agencies 

Anti-Tuberculosis  League 193 

Visiting  Nurse  Association 193 

Day  Nursery  and  Free  Kindergarten  Association 193 

Hospital  Council 193 

Society  for  the  Blind  and  a  Program  for  the  Prevention  of  Blindness 193 

Associated  Charities 196 

Association  for  the  Crippled  and  Disabled  and  the  Program  for  the  Care 

of  Cripples _ 197 

Proposed  Agencies  and  Programs  for — 

Prevention  and  Relief  of  Heart  Disease 213 

Prevention  and  Cure  of  Cancer _  221 

IV.  Summary  of  Recommendations... 226 

PART  III. 

A  Program  for  Child  Health  Work 

I.  Present  Organization _ „ 267 

II.  The  Problem 269 

III.  Proposed  Organization 270 


16  Hospital  and  Health  Survey 

Page 

IV.  Functional  Activities 273 

V.  Conclusions + 319 

PART  IV. 

Tuberculosis. 

I.  The  Story  in  Brief... 331 

II.  Objects  and  Methods 336 

III.  Statistical  Record  of  Tuberculosis  in  Cleveland 338 

IV.  General  Provisions  for  Attack  and  Defense  against  Tuberculosis 346 

V.  Special  Provisions  for  Fighting  Tuberculosis 355 

VI.  A  Summary  of  Activities  and  Equipment.... 364 

VII.  Recommendations >. 370 

PART  V. 

Venereal  Disease. 

I.  General  Statement 395 

II.  Medical  Phases.. 398 

III.  Legal  Aspects... 419 

IV.  Protective  Social  Measures. 429 

V.  Sex  Education : 431 

PART  VI. 

Mental  Diseases  and  Mental  Deficiency. 

I.  Introduction 443 

II.  City  Facilities  for  Diagnosis  and  Treatment 446 

III.  State  Facilities  for  Diagnosis  and  Treatment 467 

IV.  Courts  and   Correctional  Agencies 476 

V.  Mentally    Atypical  Children 488 

VI.  Welfare  Organizations t 497 

VII.  Prevention — -Mental    Hygiene 501 

VIII.  Summary  of  Recommendations.. 503 

PART  VII. 

Health  and  Industry. 
I.        Industrial  Medical  Service 

Introduction 525 

The  Industries  of  Cleveland 525 

Medical  Service  in  Industry..... 526 

Medical  Service  in  Non-Industrial  Establishments 535 

Medical  Service  Beyond  the  Plant 536 

Industrial  Medical  Records 53  7 

Absenteeism  Due  to  Sickness 541 

Physical  Examinations : - 542 

Special  Services 544 

The  Small  Establishment 550 

Industrial  Hospitals - 552 


Table  of  Contents  1? 

Page 

The  Training  of  Industrial  Physicians  and  Nurses 552 

Public  Health  Authorities  and  Industrial  Hygiene - —  553 

Recommendations -  554 

II.  Women  and  Industry 

Introduction _ — - 557 

Conditions  in  Various  Occupations  Employing  Women 558 

General  Discussion , . - - - 571 

Recommendations — - — -.— 575 

III.  Children  and  Industry 

Introductory - - 579 

Legal  Provisions  for  Children  15 — 18  Going  to  Work - 581 

Statistics  for  Children  in  Industry  in  Cleveland ._ 583 

Where  Children  Work - — - 588 

Health  of  Children  at  Work ... - - - 603 

Education's  Responsibility. : - - —  613 

Junior  Vocation  Departments , -- - 615 

Suggested  Plan  of  Organization  for  a  Vocational  Guidance  Bureau 617 

Summary  of  Recommendations — - -- 619 

PART  VIII. 
Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

I.  Medical  Education  and  Practice  in  Cleveland 

Medical  College  of  Western  Reserve  University 651 

Classification  of  Cleveland  Physicians  by  Specialties 663 

Hospital  Staff  Service..... '- - : 664 

Professional  Organizations - — 664 

Discussion  of  Autopsy  Service. — ,. - - 667 

Recommendations — 669 

II.  Quacks  and  Patent  Medicines,  in  relation  to  the  Foreign-Born  of  Cleveland 

The  Picture 

The  Immigrant... - — - 672 

The  Quack -■ 672 

How  the  Quack  Reaches  the  Immigrant..... —■- 674 

The  Objectives 

Means  of  Investigation  and  Prevention — — -  676 

Recommendations -  -  682 

III.  Dentistry  in  Cleveland 

Private  Practice  of  Dentistry 683 

Public  Services 684 

College  of  Dentistry 688 

The  Dental  Hygienist 689 

Recommendations 690 

IV.  Pharmacy  in  Cleveland 

Number  and  Education  of  Pharmacists 691 

Laws  Dealing  with  Pharmacy 691 

Cooperation  of  Pharmacists  with  the  Division  of  Health 694 

School  of  Pharmacy  of  Western  Reserve  University 694 


18  Hospital  and  Health  Survey 

Page 

Proposed  Manufacturing  and  Professional  Service  to  Hospitals .*..._  696 

Recommendations 697 

PART  IX. 

Nursing. 

I.  Nurses'  Training  in  Cleveland 

Hospital  Training  Schools —  709 

Post-graduate  Courses 745 

II.  Public  Health  Nursing 

Central  Nursing  Committee _ 756 

Division  of  Health _ 758 

Visiting  Nurse  Association.... 1 773 

Board  of  Education _ _ 782 

University  District '. 789 

City- wide  Prenatal  and  Maternity  Service _ 797 

Industrial  Nursing , 803 

III.  Some  Notes  on  Private  Duty  Nursing 

Unnecessary  Employment  of  Full-time  Graduate  Nurses 808 

Trained  Attendants 809 

PART  X. 
Hospitals  and  Dispensaries. 

I.  The  Care  of  the  Sick 

Resources  for  Care.. 819 

Some  Definitions ._.. 822 

II.  Hospitals 

Hospital  Provision  and  Community  Needs. 828 

Organization  for  Service 838 

The  Human  Problem  of  the  Hospital  Patient 849 

The  Medical  Profession  and  the  Hospitals 858 

Finances  and  Administration... 868 

Some  Practical  Points  of  Administration.. 877 

III.  Dispensaries 

Dispensaries  in  Cleveland - 890 

The  Public  Health  Dispensaries 901 

Policies  and  Needs - 912 

The  Down-Town  Dispensary.. 922 

IV.  Special  Problems 

The  Convalescent  and  the  Hospital. —  926 

A  Community  Program  for  Convalescent  Care -  938 

Chronic  Illness  and  Its  Care 944 

Social  Service  in  Hospitals  and  Dispensaries 952 

The  Ambulance  Service  of  Cleveland 961 

V.  Hospital  and  Dispensary  Planning 

Community  Planning 966 

Individual  Hospital  Planning... 973 

Organization  to  Carry  Out  Plans — 979 


Table  of  Contents  19 

PART  XI. 
Method,  Bibliography,  Index. 

I.  Method  of  Survey  Page 

Introduction : 1003 

Preliminary  Steps 1004 

Scope... 1005 

Aims  and  Methods... — 1 009 

Conclusions 1016 

II.  Bibliography  of  Surveys 1038 

III.  Index 1061 

TABLES 

Part  II.  Pages 

I.  Number  of  births  by  sex,  race  and  character  of  professional 

attendance,  by  health  district  231 

II.  Analysis  of  all  deaths  by  race,  under  one  year,  and  for  the 

diseases  upon  which  the  "sanitary  index"  is  calculated  232 

III.  Communicable  disease  morbidity  reports  233 

IV.  Endemic  indices  for  Cleveland  234 
V.  Group  of  diseases  included  in  the  list  upon  which  the  sani- 
tary index  is  based  236 

VI.  Report  of  the  work  of  the  district  physicians,  1919-1920  237 

VII.  Official  record  of  raw  milk  in  Cleveland  during  the  past  six 

years  238 

VIII.  Official  record  of  pasteurized  milk  in  Cleveland  for  the  past 

six  years  239 

IX.  Synopsis  of  classified  report  of  bacteriological  examination 

of  Cleveland  market  milk  240 

X.-XXXVIII.  Outline  of  a  complete  system  of  vital  statistics  for  the  health 

department  of  a  city  of  the  size  of  Cleveland  242—255 

XXXIX.-XLII.  Summary  of  the  survey  of  sanitary  conditions  in  child  car- 
ing institutions  and  of  medical  examinations  of  institu- 
tional and  boarded-out  children  255—258 

Part  IV. 

I.-V.  Tuberculosis   deaths   by   age,   years,   sex,   occupation   and 

forms  378-379 

VI.-VII.  Attendance  at  Health  Centers  379 

VIII.-XIII.  Tabulation  of  Milk  Consumption  Study  380-382 

Part  VII. 

I.  Classification  of  Industrial  Organizations  622 

II.-V.  Analysis  of  Medical  Service  in  Industry  622—623 


20  Hospital  and  Health  Survey 

Page 

VI. -VIII.  Analysis  of  Accident  Frequency  and  Severity  Rates  624—625 
IX. -X.  Classification     of    Industrial     Establishments    Employing 

Women  626-627 
XI. -XV.  Classification    of    Conditions    under  Which    Women    Are 

Employed  628-630 

XVI.-XIX.  Employment  of  Children,  by  Age  and  Sex  631-632 

XX.-XXII.  Employment  of  Children,  by  Occupation  633-635 

XXIII.  Analysis  of  School  and  Physical  Records  of  Newsboys  636 

XXIV-XXVI.  Tabulation  of  Examinations  of  Children  Seeking  Employment  637-639 

Part  X. 

I.  Listing  of  Hospitals  and  Dispensaries  984 

II.  Percentage  of  Occupancy  of  Hospitals  986 
III. -IV.  Relationship  of  Hospital   Locations   and  Admissions  and 

Health  Districts  987-988 

V.  Source  of  Request  for  Admission  of  Hospital  Patients  988 

VI.  Expanses  and  Earnings  of  Hospitals  990 

VII.  Summary  of  Study  of  Convalescent  Cases  991 

VIII.  Length  of  Stay  of  Hospital  Patients  991 

IX.   Suggested  Summary  Report  Form  for  Hospitals 

and  Dispensaries  992 


ILLUSTRATIONS 

Part  I. 

Typical  housing  conditions  in  Cleveland's  congested  districts  50—51—52 

Illustrations  of  failure  of  Street  Cleaning  and  Garbage  Disposal  systems  69—70 

Part  IV. 

Where  Tuberculosis  comes  from  358 

Where  Tuberculosis  goes  to  359 

Part  VI. 

Illustrations  contrasting  treatment  of  mental  cases  at  the  Cleveland  City 

Hospital  with  their  treatment  elsewhere  448—457—459 

Part  VII. 

"Declaration  of  Dependence."     Children  and  Industry  578 

Part  VIII. 

Typical  patent  medicine  advertisements  680 


Table  of  Contents  .  21 

DIAGRAMS  AND  MAPS 

Part  I.  Page 

Map  showing  population  distribution  and  health  districts —  Facing  page  38 

Charts  of  Cleveland's  comparative  and  expected  growth  of  population  40 

Map  showing  water  supply,  sewerage  and  sewage  disposal  developments  63 

Part  II. 

Diagram  of  Cleveland  city  government  organization.     Fig.  I.  167 

Map  showing  census  tracts  (sanitary  areas).     Fig.  II. —  Facing  Page  114 

Map  showing  location  of  facilities  for  prevention  and  treatment.     Fig.  III.         117 
Map  showing  birth  rate,  stillbirth  rate,  infant  death  rates,  estimated  num- 
ber of  mothers  under  prenatal  care  and  number  of  children  under  care  of 
prophylactic  stations,  by  health  districts.     Fig.  IV.  118 

Graph  showing  the  death  rate  of  each  of  25   cities  in  the  United  States. 

Fig.  V.  120 

Graph  showing  "Sanitary  Index"  for  the  years  1885-1920.     Fig.  VI.  128 

Graph  showing  deaths  in  Cleveland  from  all  causes  for  diseases  on  which  the 

Sanitary  Index  rate  is  calculated.     Fig.  VII.  129 

Graph  showing  death  rates  for  eight  important  communicable  diseases  in 
Cleveland  and  in  all  cities  included  in  the  registration  area,  for  the  years 
1913-17,  and  the  death  rates  during  1917  for  these  same  diseases  in  Cleve- 
land, the  cities  and  the  states  of  the  registration  area.     Fig.  VIII.  130 
Graph  illustrating  the  morbidity  incidence  of  tuberculosis,   four  common 
acute  communicable  diseases  of  childhood  and  of  venereal  diseases,  by 
health  districts.     Fig.  IX.  131 
Figure  illustrating  same  data  as  Fig.  IX.  by  health  district  map.     Fig.  X.         132 
Graph  illustrating  the  relative  position  of  the  health  districts  by  registered 

births  and  deaths.     Fig.  XI.  133 

Graph  showing  an  analysis  of  death  rates  from  all  causes  and  from  various 

communicable  diseases,  by  health  districts.     Fig.  XII.  134 

Illustrating  same  data  as  Fig.  XII.  by  health  district  map.     Fig.  XIII.  135 

Graph  representing  suggested  organization  of  services  for  boarded-out  chil- 
dren.    Fig.  XIV.  179 

Part  III. 

Diagram  showing  organization  of  Proposed  Central  Child  Hygiene  Council         271 
Graph  showing  incidence  of  defects  in  children  by  age  and  sex  304 

Part  IV. 

Map  showing  distribution  of  tuberculosis  facilities  330 

Graph  showing  death  rates  from  pulmonary  tuberculosis  and  non-tuberculous 
pulmonary  diseases  from  1852  to  1917  341 

Part  V. 

Map  showing  attendance  at  venereal  disease  clinics,  by  health  districts  405 


22  .  Hospital,  and  Health  Survey 

Part  VII.  Page 

Two  maps  showing  location  of  industrial  establishments  548—549 

Part  X. 

Map  showing  location  of  hospitals,  dispensaries  and  health  centers.     Fig.  I.  823 

Chart  showing  provision  and  need  for  hospital  beds.     Fig.  II.  836 
Map  showing  residence  of  2,500   dispensary  patients  by  health   districts. 

Fig.  III.  891 

Chart  showing  inter-relation  between  hospital  and  dispensary.     Fig.  IV.  898 


Hospital  and  Health  Survey  of  Cleveland,  Ohio 


A  Report  Presented  to  the  Committee  on  Survey  of  the  Cleveland 

Hospital  Council 

By 

Haven  Emerson,  M.  D.,  Director, 
and  the  following  collaborators: 

Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 

Michael  M.  Davis,  Jr.,    Ph.  D.,  Director  of  the  Hospital  and 
Dispensary  Survey; 

Josephine  Goldmark,  A.  M.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 


Introduction 

By  Haven  Emerson,  M.  D. 

"A  few  great  points  steadily  reappear,  alike  in  the  poverty  of  the  obscurest 
farm  and  in  the  miscellany  of  metropolitan  life.  *  *  *  *  .  These  few  are 
alone  to  be  regarded:  the  escape  from  all  false  ties;  courage  to  be  what  we 
are;  and  love  of  what  is  simple  and  beautiful;  independence,  and  cheerful 
relations,  these  are  the  essentials — these  and  the  wish  to  serve — to  add  some- 
what to  the  well-being  of  men." 

THE  habit  of  mind  or  of  work  which  prevails  in  the  United  States  is 
rather  to  move  from  the  practical  to  the  theoretical  than  in  the  reverse 
order.  As  is  natural  in  a  young  nation  free  from  the  established  pro- 
cedures and  precedents  of  government  and  personal  conduct  which  domi- 
nate the  life  of  older  countries,  we  see  a  need,  we  move  to  meet  it,  -we  pres- 
ently suspect  our  method  or  results  might  be  improved,  we  collect  records, 
study,  evolve  a  theory  and  perhaps  then  begin  to  apply  the  principles  evolved 
to  new  undertakings  in  the  same  direction.  We  have  not  evolved  a  theory 
and  principles  of  health  development,  of  health  protection,  of  disease  preven- 
tion, of  death  postponement.  It  has  been  one  of  the  illuminating  educa- 
tional features  of  our  contact  with  the  keenly  analytical,  the  intellectually 
honest  minds  of  our  French  colleagues  during  the  war  that  we  have  met  a 
system  of  education  and  practice  which  begins  with  theory  and  principle, 
and  gradually  through  individual  and  ultimately  through  government  action 
arrives  at  application  of  theory  to  practical  needs. 

This  report  is  a  contribution  to  the  study  of  current  facts,  accomplish- 
ments, undertakings  in  the  field  of  medico-social  service.  Theory  is  not 
within  the  plan  of  this  presentation,  but  it  is  hoped  that  by  the  study  of 
facts,  by  the  application  of  recommendations,  theory  may  be  tested  and  the 
philosophy  of  social  organization  for  the  attainment  of  health  and  its  main- 
tenance may  be  advanced. 

Those  of  us  who  have  shared  in  this  study  are  perforce  enthusiasts,  if 
you  will,  fanatics,  crusaders  in  what  we  believe  is  to  prove  the  greatest  con- 
tribution of  this  generation  to  the  success  of  a  representative  and  demo- 
cratic social  order :  namely,  civil  and  social  organization  for  health.  Neither 
forms  of  government  nor  systems  of  society  will  long  endure  unless  the  health, 
mental  and  physical,  of  the  people  is  accepted  as  a  matter  of  official  and 
individual  concern,  in  importance  second  only  to  the  administration  of  jus- 
tice, provision  of  education,  liberty  of  speech  and  of  religious  observance. 

This  is  not  the  place  to  press  the  argument.  Personal  experience  and 
government  documents  in  abundance  provide  the  data  from  which  students 
will  decide  the  amount  and  distribution  of  wastage  from  sickness  and  pre- 
mature death.  No  expression,  in  terms  of  money  equivalent  of  human 
labor,  of  this  burden  upon  life,  this  deficit  in  happiness,  adequately  repre- 
sents the  true  total,  but  even  to  the  so-called  practical  man,  that  much 
abused  man-in-the-street  who  is  supposed  to  be  merely  a  mechanical  adding 
machine  without  sympathies,  emotions  or  imagination,  the  figures  are  im- 
pressive. 

Expressed  for  the  population  of  Cleveland  and  its  suburbs,  roughly  a 


26  Hospital  and  Health  Survey 

population  of  1,000,000  within  Cuyahoga  County  in  1920,  and  using  the 
death  and  sick  rates  experience  of  70  per  cent  of  the  total  population  of 
continental  United  States  in  1916,  and  the  sickness  census  in  various 
cities,  such  as  Pittsburgh,  Boston  and  Rochester  in  recent  years  as  appli- 
cable to  the  experience  in  Cleveland  in  1920,  we  must  picture  about  two  per 
cent  of  all  the  people  all  the  time  too  sick  to  work  or  be  up  and  about,  from 
causes  of  which  one-half  are  certainly  preventable. 

In  1919  the  cost  of  illness  and  death  from  communicable  diseases  alone 
in  Cleveland,  based  on  the  very  conservative  estimates  of  value  of  life  and  cost 
of  sickness,  burial,  etc.,  used  in  a  study  in  Illinois*  must  have  been  not  less 
than  $25,000,000.  To  this  must  be  added,  among  other  items,  the  cost  of 
death  and  disease  due  to  preventable  but  non-communicable  forms  of  disease 
and  the  cost  of  $200  a  year  for  each  insane  person  and  $160  a  year  for  each 
feeble-minded  person  cared  for  in  institutions. 

Further,  we  must  recognize  that  not  less  than  35  per  cent,  and  in  some 
places  as  much  as  75  per  cent,  of  dependency  seeking  relief  from  public  or 
private  sources,  is  due  to  sickness.  To  say  that  dependency  is  in  large  meas- 
ure due  to  sickness  is  merely  the  corollary  of  the  statement  that  the  average 
of  independence  is  everywhere  lowered  by  sickness,  and  upon  independence 
our  whole  social,  family  and  labor  structure  is  based. 

Three  services  we  shall  always  need  if  we  intend  to  provide  the  best  that 
science  affords  to  heal  the  sick  and  to  guard  the  well  against  disease.  Each 
service  although  indispensable  by  and  for  itself  is,  however,  necessarily  de- 
pendent upon  the  other  two  for  its  complete  usefulness  and  application,  and 
no  one  can  be  omitted  without  sacrifice  of  much  of  the  value  of  the  others. 

Diagnosis  and  Treatment  of  the  sick  comes  first  to  mind  as  it  was  first 
to  be  provided,  but  first  by  a  narrow  margin  of  time  before  the  Teaching  of 
Medicine.     These  two  led  by  many  ages  the  third,  the  Prevention  of  Disease. 

We  have  won  our  way  from  an  attitude  of  passive  submission  or  accept- 
ance of  disease  and  disability  as  inflictions  of  fate,  of  some  evil  genius,  or  by 
the  gods  or  our  own  Divinity,  through  the  self-respecting  and  upright  posi- 
tion of  self-defense  against  disease,  using  the  weapons  of  science,  until  we 
are  now  moving  aggressively  forward  attacking  disease  and  determined  to 
overcome  it  by  all  the  resources  of  society  as  well  as  of  science,  by  instilling 
into  people  the  hope,  the  promise,  the  certainty  of  health,  as  well  as  by  as- 
sembling, coordinating,  directing  with  our  knowledge  of  preventive  medicine 
and  organized  government  a  continuous  warfare  upon  all  the  physical, 
biological,  economic  and  spiritual  handicaps  against  which  man  and  child 
cannot  successfully  make  progress  alone. 

First,  and  first  by  a  long  interval  among  the  weapons  of  attack,  comes 
education,  not  alone  the  training  of  the  intelligence,  the  distribution  of  facts, 
but  the  development  of  the  feelings,  the  emotions,  the  instinctive  reactions 
which  guide  us  chiefly  in  the  emergencies  and  great  decisions  of  life.  The 
channels  of  this  education  are  not  alone  the  schools  and  colleges  but  the  indi- 
vidual field  workers,  the  physicians,  the  nurses,  the  public  health  officers, 
the  social  workers,  the  school  teachers  who  make  contact  with  the  homes. 
Health,  its  attainment,  its  defense,  its  prolongation,  cannot  be  taught  all 

•Hemenway,  American  Journal  of  Public  Health    Vol.  10,  Number  2,  February,  1920. 


Introduction  27 

the  time  to  all  the  people,  and  to  but  few  and  for  but  short  periods,  through 
the  public  press  or  the  distribution  of  so-called  "literature"  and  propaganda 
by  pictures,  posters,  etc. 

Rarely  there  comes  the  great  teacher,  one  who  compels  attention  by  his 
knowledge  or  his  art,  a  Franklin,  a  Pasteur,  an  Osier,  but,  in  the  main, 
health  teaching,  except  to  the  few  training  for  certain  professions,  will  be 
given  effectively  only  to  those  who  are  for  one  reason  or  another  teachable. 
Children  are  teachable  because  youth  is  acquisitive  and  interested  in  itself 
and  all  that  concerns  its  body  and  its  playmates.  Mothers  are  teachable 
for  the  sake  of  their  babies.  Perhaps  one  may  include  both  parents  some- 
times in  this  class,  while  their  children  are  still  dependent.  The  sick  and 
suffering  are  generally  teachable  from  self-interest,  from  hope,  from  humility. 
In  the  presence  of  epidemic  disease  of  the  kinds  such  as  influenza  and  infantile 
paralysis,  against  which  we  have  no  reliable  measures  of  defense,  everyone 
can  be  taught  the  elements  of  personal  hygiene  and  good  health  habits 
because  of  the  fear  of  death. 

The  first  three  groups  include  all  the  community  at  some  periods  of 
their  lives  and  we  owe  them  guarantee  that  the  physicians,  nurses,  teachers 
and  others  whom  they  are  beholden  to  at  these  periods  for  care  and  instruc- 
tion, themselves  know  what  must  be  taught  and  furthermore  practise  what 
they  preach. 

In  this  guarantee  we  fail  at  present.  What  can  be  done  to  protect  those 
who  are  uninstructed  must  be  done  for  people  rather  than  by  them,  and  here 
we  come  upon  the  functions  of  the  public  and  private  agencies  for  disease 
prevention.  In  this  field  we  are  emerging  from  the  era  when  the  health 
officer  was  a  lawyer,  a  policeman,  a  scavenger,  a  mere  clerk,  to  the  concep- 
tion of  the  health  officer  as  a  leader  in  social  organization,  a  student  of  dis- 
ease as  it  occurs  in  groups,  an  administrator  of  services  which  make  life 
more  secure  and  happier  in  every  household,  in  reality  the  family  physician 
of  the  community,  its  trusted  advisor  and  protector. 

For  those  whom  our  education  and  our  devices  for  prevention  have  been 
of  no  avail,  the  sick  and  injured  of  medical  practice,  the  wastage  resulting 
from  our  ineffectiveness  in  protection,  we  provide  the  physician,  the  visiting 
nurse,  the  dispensary,  the  hospital,  the  convalescent  care.  That  there  should 
be  so  much  more  needed  to  pay  the  cost  of  repair  work  than  is  thought  suf- 
ficient to  spend  for  prevention  is  a  commentary  upon  our  intelligence,  a  sharp 
reminder  of  our  wastefulness,  of  our  undeveloped  business  acumen. 

In  the  chapters  which  follow  there  will  be  given  a  description  of  the 
services  provided  in  Cleveland  for  the  prevention  of  disease  and  for  the 
care  of  the  sick,  including  description  of  the  facilities  for  training  those  who 
contribute  to  this  care.  Where  there  are  defects  they  will  be  pointed  out, 
with,  where  possible,  specific  recommendations  for  their  remedy.  So  a 
diagnosis  and  treatment  for  the  city  will  be  developed  in  a  way  similar  to 
the  method  used  in  the  physician's  office  or  hospital. 

We  were  invited  to  Cleveland  to  learn  and  to  state  the  facts  and  if  more 
emphasis  appears  to  be  put  upon  shortcomings  than  upon  excellencies  it 
is  not  because  the  latter  were  not  observed  and  admired,  but  that  extensive 


28  Hospital  and  Health  Survey 

comment  upon  the  bright  eyes  and  rosy  cheeks  of  the  patient  seems  mal- 
apropos when  there  is  a  dressing  to  do  for  a  broken  arm. 

For  convenience  in  distribution  of  the  report  to  students  and  workers 
in  the  various  special  fields  of  hospital  and  health  work  the  text  is  divided 
into  eleven  parts. 

Under  General  Environment  and  Sanitation,  Part  I,  will  be  found  de- 
scription of  those  elementary  factors  upon  which  are  based  an  estimate  of 
the  standards  of  living  attained  by  a  community.  The  reader  will  wish  to 
know  the  area  and  population,  something  of  the  geology  and  the  nationali- 
ties, and  what  the  history  of  growth  predicts  for  future  needs.  As  life  and 
the  success  or  failure  we  make  of  it  is  largely  a  matter  of  our  ability  to  adapt 
ourselves  to  natural  and  artificial  variations  in  environment,  we  are  inter- 
ested in  Nature's  allotment  of  weather  to  this  man-picked  site  for  a  great 
human  aggregation.  What  man  does  to  his  fellow-men  is  certain  to  be  more 
of  a  menace  than  what  the  elements  dispense,  and  his  home,  where  his  chil- 
dren are  reared,  where  he  and  his  wife  and  the  little  ones  spend  the  major 
part  of  their  time,  is  found  here  as  it  is  elsewhere  in  our  cities  commonly 
far  below  the  limit  either  of  our  means  or  of  our  knowledge  or  of  our  legal 
requirements  for  healthy  liviDg. 

The  blessing  of  pure  water  is  within  his  reach,  and  in  the  main  there  is 
good,  provision  for  disposal  of  his  wastes,  for  man,  like  bacteria,  cannot  live 
long  in  the  midst  of  his  own  offal  and  dirt. 

With  his  air  the  Clevelander  is  not  so  fastidious  and,  although  it  is  sup- 
posed to  be  the  only  remaining  necessity  of  life  still  free  for  the  humblest 
citizen,  yet  we  find  a  filthiness  of  air  which  robs  the  child  of  its  breath,  the 
sun  of  its  strength,  the  sky  of  its  precious  color,  and  simply  because  of  habit 
and  unneighborliness,  the  habit  of  ignoring  coal  smoke  as  a  public  nuisance 
and  indifference  to  the  inconvenience  caused  to  the  other  fellow  by  your 
own  belching  chimney. 

In  Part  II.  we  deal  with  the  dual  machinery  of  public  and  private  organ- 
ization for  health  protection.  After  outlining  the  basis  in  law  and  in  local 
government  administration  for  the  powers  and  services  of  various  depart- 
ments which  contribute  to  health  in  Cleveland,  the  Division  of  Health  and 
its  bureaus  are  described  and  analyzed.  The  parsimony  of  public  appro- 
priating bodies  in  matters  of  insurance  against  disease  and  death  through 
investment  in  the  services  of  doctors  and  nurses  is  in  striking  contrast  with 
the  liberal  use  of  tax  money  to  protect  property  against  violence  and  fire. 
There  are  defects  in  personnel,  organization  and  inadequacy  of  resources, 
but  that  there  is  a  record  of  important  and  encouraging  accomplishment 
cannot  be  doubted. 

Without  a  service  for  public  education  for  legitimate  civic  advertising  of 
needs  and  opportunities  in  health  protection  any  health  service  is  sadly  crip- 
pled.    This  is  the  case  in  Cleveland. 

Official  protection  of  industrial  workers  against  health  hazards  is  needed 
and  would  be  welcomed,  but  it  is  not  offered  in  the  present  health  service. 

The  childien  of,  the  parochial  schools,  the  children  of  pre-school  age, 
the  expectant  mother,  all  lack  the  life  saving  service  which  is  offered  at 
public  expense  in  some  other  cities. 


Introduction  29 

As  the  family  physician  of  the  city  the  Commissioner  of  Health  should  be 
provided  with  physicians  to  maintain  supervision  over  the  health  of  those 
children  whose  lives  are  spent  in  the  unnatural  environment  of  institutions. 
This  he  cannot  do  at  present. 

Among  the  existing  bureaus  there  is  none  needing  such  a  radical  overhaul- 
ing as  the  Bureau  of  Vital  Statistics.  An  adequate  record  of  human  liabili- 
ties and  assets  is  indispensable  to  intelligent  public  health  work.  A  concep- 
tion is  presented  of  the  possibilities,  the  necessities,  the  advantages  of  a  true 
demographic  office  and  reports  for  the  city,  a  model  for  a  municipality,  an 
example  which  if  followed  would  elevate  the  city,  the  state  and  the  nation 
in  the  estimation  of  thoughtful  people  here  and  abroad. 

One  of  the  archaisms  of  our  civil  government  is  disclosed  in  the  per- 
sistence of  the  coroner's  system.  Until  Cleveland  follows  the  example  of 
Boston  and  New  York  in  establishing  this  function  under  non-political, 
competent  pathologists  there  will  be  inefficiency,  graft  and  the  cloaking  of 
crime  under  the  forms  and  appearance  of  law. 

Everywhere  we  find  private  energy  and  sympathy  organized  to  supple- 
ment public  service.  This  is  particularly  the  case  in  preventive  and  relief 
work  for  the  sick.  The  crippled,  the  blind,  the  lame  in  heart  and  mind 
always  will  be  sought  out  and  assisted  to  such  happiness  and  occupation  as 
they  can  attain.  Sooner  or  later  the  wish  to  prevent  rises  into  effective  effort 
and  real  health  protection  develops.  There  are  in  Cleveland  as  elsewhere 
special  agencies  for  the  care  of  the  many  handicapped,  and  the  special  merit 
of  Cleveland  is  in  the  successful  coordination  of  support  and  direction  of 
many  of  these  medical  and  social  services  maintained  by  private  resources. 
These  are  described  in  some  detail  in  the  chapter  on  Private  Health  Services 
and  the  total  of  undertakings  is  certainly  impressive,  in  spite  of  the  gaps, 
which  it  is  hoped  will  soon  be  filled. 

Although  the  subject  matter  of  Part  III.  deals  with  many  important 
functions  and  accomplishments  of  the  Division  of  Health,  and  as  well  in- 
cludes description  and  discussion  of  auxiliary  private  agencies,  the  leading 
role  of  the  child's  health  as  the  objective  of  the  great  majority  of  private  and 
public  health  services  made  it  seem  wise  to  set  apart  this  program  in  its 
entirety  from  the  general  field  covered  in  Part  II.  Probably  in  no  subject 
of  public  health  work  will  the  results  of  a  logical  and  thorough  integration 
of  the  public  and  private  agencies  bring  such  economies  in  cost  and  per- 
sonnel and  such  large  returns.  A  good  beginning  has  been  made  in  pre- 
natal care  of  expectant  mothers;  a  start  upon  service  for  the  children  be- 
tween two  and  six  years,  the  pre-school  child,  is  assured;  important  im- 
provements in  public  protection  of  the  child  in  industry  are  under  way.  In 
the  public  schools,  and  more  particularly  in  the  parochial  schools,  there  is 
need  of  thorough  medical  examination  and  home  follow-up  by  nurses. 

Except  for  the  defects  of  development,  nutrition  and  exposures  to  infec- 
tion which  result  from  the  child's  handicaps  of  home  environment,  the  most 
serious  defect  in  the  provision  made  by  the  public  for  children  during  the 
years  of  compulsory  school  attendance  is  the  quality  of  air  permitted  in  the 
school  rooms.  In  the  majority  of  school  rooms  and  in  all  those  in  the  newer 
school  buildings  the  systems  of  so-called  mechanical  ventilation  are  in  con- 
trol of  the  child's  vitality.     Laws,  more  in  the  interest  of  building  contrac- 


30  Hospital  and  Health  Survey 

tors  and  engineers  than  of  children's  health,  impose  a  plan  of  so-called  venti- 
lation which  is  really  a  kind  of  slow  strangulation  process.  The  open  window 
has  been  shut  by  law.  Children's  health  requires  open  window  ventilation 
all  the  year  round.  The  laws  must  be  changed  and  school  management  be 
so  arranged  that  the  air  in  class  rooms  may  be  freely  flowing,  cool  and  fresh, 
with  as  nearly  as  practicable  the  relative  humidity  of  outdoor  air. 

Tuberculosis  in  Cleveland,  which  is  dealt  with  in  Part  IV.,  is,  first  of  all, 
a  study  of  incidence  and  distribution,  necessarily  incomplete  because  of  the 
inadequacy  of  the  records  of  population,  deaths  and  sickness,  but  sufficient 
to  show  the  unfinished  work,  the  need  of  renewed  attack  and  the  ways  which 
have  proved  helpful  elsewhere.  In  this  subject,  as  in  the  following  one  of 
Venereal  Diseases,  we  are  face  to  face  with  a  problem  of  social  contacts. 
No  mere  medical  knowledge,  no  public  or  private  health  organizations  alone 
will  accomplish  the  reduction  or  control  of  the  spread  of  tuberculosis.  As 
man's  own  habits,  his  customs,  his  environment  artificially  created,  are  the 
multitudinous  contributory  factors  both  to  infection  and  to  active  expression 
of  the  disease,  so  it  must  be  through  a  spread  of  knowledge,  through  intelli- 
gent, clean  living,  through  the  abatement  of  injustices  which  tax  the  nourish- 
ment, the  rest,  the  peace  of  mind  of  those  of  modest  means  that  we  must 
look  for  diminution  of  tuberculosis,  as  well  as  through  the  greater  skill  of 
physicians  in  the  early  detection  and  in  the  arrest  of  active  tuberculous 
disease. 

While  tuberculosis  remains  the  cause  of  something  over  12  per  cent  of  all 
deaths  and  responsible  for  the  most  costly  of  all  sicknesses,  and  while  we 
do  not  know  the  fact  of  sickness  before  death  in  at  least  30  per  cent  of  all 
persons  dying  of  tuberculosis,  there  needs  no  elaborate  exposition  of  our 
social  and  official  shortcomings.  The  report  upon  the  exact  conditions  in 
Cleveland  will  certainly  lead  to  a  stronger  determination  and  a  more 
generous  support  for  medical  and  social  agencies  engaged  on  this  problem. 

The  so-called  American  Plan  for  the  control  of  venereal  disease  is  used 
in  Part  V.  to  measure  Cleveland's  accomplishment.  From  being  a  subject 
of  technical  discussion  among  specialists  at  medical  society  meetings  the 
problem  of  control  of  syphilis  and  gonorrhea  has  aroused  open  discussion  on 
the  floor  of  Congress,  has  enlisted  the  joint  action  of  three  of  the  most  power- 
ful departments  of  the  Federal  Government,  is  accorded  earnest  considera- 
tion and  intelligent  discussion  in  state  legislatures  and  has  been  raised  from 
shame  and  silence  into  the  range  of  decent  educational  publicity. 

It  is  not  for  physicians,  nurses,  hospital  superintendents  and  health  officers 
that  this  subject  is  here  dealt  with.  The  origins  of  syphilis  and  gonorrhea 
are  so  intricately  beset  with  social  factors  that  although  the  scientific  facts 
of  etiology  and  diagnosis,  the  course  of  the  diseases  and  their  treatment 
have  given  the  courage  of  knowledge  in  our  campaigns,  still  by  education 
in  character,  self-restraint,  control  of  the  brute  in  us  by  our  better  natures 
and  by  sparing  our  children  the  unfavorable  contributory  factors  in  employ- 
ment, conduct,  recreation  and  opportunity  which  have  generally  prevailed 
until  now,  we  can  do  as  much  through  social  organization  as  through  health 
services.  As  the  text  of  the  chapters  will  show  there  is  ample  opportunity 
for  advance  along  lines  to  suit  the  inclinations  of  the  lay  worker,  as  well  as 
the  practitioner  or  student  in  laboratory  research. 


Introduction  31 

Part  VI.  gives  a  picture  which  will  develop  humility  in  thinking  people. 
With  our  vaunted  humanity  and  practical  efficiency  we  prove  ourselves 
inhuman  in  our  collection  and  treatment  of  the  most  pitiful  of  human  wreck- 
age and  inefficient  in  our  indifference  to  the  debt  of  feeble-mindedness  and 
insanity  we  are  permitting  to  be  piled  up  for  the  next  generation,  by  failure 
to  provide  for  segregation  and  institutional  care  for  the  thousands  now  at 
large  in  the  homes  of  the  city. 

No  more  scathing  comment  upon  civil  administration  could  be  made 
than  the  description  of  the  kind  of  care  provided  for  the  mentally  afflicted  at 
City  Hospital.  Could  this  have  occurred  if  there  had  been  an  active,  alert, 
interested  group  of  physicians  and  others  organized  to  help  the  problems  of 
mental  hygiene,  the  interests  of  the  mentally  lame,  the  opportunities  for 
prevention  and  education  in  Cleveland?  Probably  not,  and  certainly  one  of 
the  results  of  the  present  brilliant  statement  of  the  situation  should  be  the 
establishment  of  a  local  mental  hygiene  committee  affiliated  with  the  national 
body  of  this  name. 

Part  VII.,  the  volume  on  the  Medical  Services  in  Industry,  Women 
and  Industry,  and  Children  and  Industry,  represents  the  first  effort  in  this 
country  or,  so  far  as  we  are  aware,  elsewhere,  to  see  the  broad  landscape  of 
this  new  professional  country.  Where  are  the  workers?  How  distributed 
in  large  and  small  plants?  What  the  quantity  and  quality  of  the  profes- 
sional care  provided  for  them?  What  is  to  be  expected  from  reasonable  care 
of  the  workers  in  terms  of  production  and  of  producers?  Such  are  questions 
that  await  answers.  To  quote  from  the  first  chapter  of  the  report,  "Cleve- 
land is  an  industrial  community ;  the  greatest  common  interest  of  her  people 
is  her  industries,  and  those  of  her  people  who  labor  therein  are  the  life  of 
the  city.  The  future  of  Cleveland  depends  upon  the  well-being  and  the 
happiness  of  her  industrial  workers  and  to  secure  and  safeguard  their  health 
is  the  vital  task  of  industrial  medical  service." 

Such  services  are  understood  by  the  few  leaders  and  the  methods  and 
results  are  matters  of  record  for  those  who  wish  to  learn.  The  city  awaits 
and  needs  the  advantages  of  these  services,  the  results  of  which  can  be 
guaranteed. 

That  there  should  be  more  than  twenty-two  thousand  women  occupied  in 
industry  may  seem  a  small  quota  to  take  from  the  home  makers  of  a  city  of 
800,000  people,  but  as  a  unit  exposed  to  varied  and  serious  risks,  as  a  great 
army  of  possible  or  prospective  or  present  mothers,  the  interest  of  the  state 
in  their  safety  and  continued  health  is  large.  That  there  are  special  physical 
disabilities  acquired  by  women  in  apparently  safe  and  reasonable  work  is 
well  known.  That  fatigue  plays  a  more  serious  part  in  the  damage  to 
women's  health  than  is  generally  found  among  men,  or  at  least  expresses 
itself  in  a  variety  of  troublesome  nervous  affections,  is  seen  in  some  industries. 
That  women  should  be  excluded  from  night  work  is  perhaps  too  obvious  to 
argue.  Now  with  .the  facts  before  us,  it  is  safe  to  say  that  with  the  increas- 
ing power  of  women  in  organization  and  self-determination  it  will  not  be  long 
before  remedies  are  found  for  the  worst  evils.  The  women  of  Ohio  certainly 
need  the  rights  of  suffrage. 

How  loosely  we  count  our  treasures,  how  careless  we  are  of  the  strength 
of  our  men  and  women  in  the  making,  is  told  in  the  story  of  children  in  in- 


32  Hospital  and  Health  Survey 

dustry.  Not  a  lurid  tale  of  child  slavery  but  an  inventory  of  the  pros  and 
cons  of  this  undesirable  element  in  national  wealth.  The  strengthening  of 
laws  will  accomplish  something,  their  better  enforcement  still  more,  but  the 
final  answer  to  the  question  of  children  in  industry  will  be  given  only  when 
parents  see  that  in  education  and  vocational  training  there  is  a  greater  return 
in  maturity  than  the  early  earnings  of  children  can  provide. 

In  Parts  VIII.  and  IX.  the  profession  of  medicine  and  its  associates,  in 
service  to  the  sick  are  dealt  with,  the  training  provided  for  them  and  the 
relations  of  their  licensed  practitioners  to  preventive  and  curative  medicine. 
This  involves  a  consideration  of  the  University  which  mothers  them  all,  her 
limitations,  and  wherein  her  children  suffer  from  lack  of  educational  pabu- 
lum. Much  is  asked  of  the  University  in  the  way  of  new  undertakings  in 
the  educational  field,  all  depending  on  the  sinews  of  war — the  state  of  the 
University  treasury.  Much  is  expected,  however,  by  the  injection  of  a 
more  active  leadership  and  initiative  among  trustees  and  teachers.  The 
governing  and  teaching  bodies  need  a  generous  dose  of  democracy  and  a 
sense  of  personal  responsibility  for  a  closer  touch  with  the  needs  of  the  com- 
munity. The  visions  of  a  great  installation  will  all  in  time  come  true,  but 
even  without  fine  structures,  conditions  can  be  provided  which  will  attract 
and  hold  that  quality  of  brains  upon  which  alone  great  schools  are  built. 

In  the  practice  of  medicine  certain  characteristics  are  apparent  which 
pertain  more  to  the  era  of  small  town  existence  than  to  the  service  of  physi- 
cians in  a  modern  metropolis.  Lack  of  use  and  consideration  for  the  special- 
ties in  medicine  and  surgery  are  striking  to  those  familiar  with  practice 
farther  east  in  the  United  States,  and  in  European  cities.  Entertainment  as 
well  as  cause  for  serious  action  will  be  found  in  the  study  of  those  harpies 
who  fatten  on  the  credulity  and  ignorance  of  our  foreign  tongue  immigrants, 
the  irresponsible  and  illegal  practitioner,  the  advertising  quacks. 

Dentistry  and  Pharmacy  each  present  professional  problems  of  impor- 
tance which  cannot  be  ignored  without  loss  of  some  measure  of  help  to  the 
public  in  the  care  of  the  sick.  Their  contributions  to  preventive  medicine 
also  are  considerable  and  increasing  in  value. 

So  extensive  has  the  field  of  nursing  become,  so  dependent  are  we  in  all 
directions  of  medical  and  public  health  practice  upon  this  army  of  the  trained 
sisterhood,  that  a  study  of  their  profession  by  a  rarely  well  equipped  group 
of  their  own  graduates  and  leaders  is  particularly  appropriate  and  most 
fortunate  for  this  Survey.  Nothing  comparable  to  this  has  been  done  for 
the  nursing  profession  before,  and  although  studies  of  national  extent  are 
under  way,  Cleveland  will  now  be  in  a  particularly  favorable  condition  to 
make  good  its  present  lead  in  strategic  features  of  nursing  education  and 
practice,  while  waiting  for  the  report  of  the  National  Committee  from  which 
we  borrowed  the  director  and  several  of  the  workers  for  our  own  study. 

Nurses  training  in  the  past  and  often  still  presenting  a  rather  sorry  pic- 
ture of  mingled  exploitation  of  willing  labor  and  amateurish  teaching,  is 
worthily  described.  Practical  means  are  proposed  to  meet  the  obligations 
of  hospitals  to  both  patients  and  nurse  pupils. 


Introduction  33 

Public  Health  Nursing  includes  thorough  discussion  of  the  services  ren- 
dered in  the  many  public  and  private  organizations  engaged  in  educational 
and  bedside  work  through  field  nurses. 

Private  nursing,  too,  though  not  a  matter  of  chief  importance  from  the 
point  of  view  of  the  Survey  has  had  an  illuminating  brief  study  put  upon  it. 

It  was  in  the  minds  of  the  Trustees  of  the  Cleveland  Hospital  Council  that 
the  conception  of  this  Survey  originated,  and  it  was  their  declaration  that  the 
hospital  is  really  a  public  service  institution,  responsible  alike  for  prevention 
and  for  care  of  disease,  that  became  the  keynote  of  our  program.  Since  pre- 
vention is  the  spirit  of  modern  medicine  the  machinery  for  its  accomplish- 
ment has  had  precedence  in  the  order  of  chapters  over  the  description  of 
those  services  which  have  always  been  primarily  devoted  to  cure,  relief  or 
post]  o  lenient  of  death  amongst  the  seriously  ill . 

In  Part  X.  will  be  found  not  only  a  recital  of  the  physical  and  profes- 
sional resources  of  the  community  in  the  shape  of  hospitals,  dispensaries 
and  their  accessory  services  beyond  their  walls,  but  the  spirit,  the  philosophy, 
the  ideals  which  imbue  the  present-day  executives  of  these  centers  of  skill, 
tenderness  and  teaching.  From  cellar  to  garret  the  investigators  have 
searched  for  the  good  and  the  poor  in  hospital  management.  From  the 
admitting  desk,  or  rather  from  the  doorstep,  of  the  hospital  where  the  dis- 
appointed applicant  is  declined  admission,  to  the  report  of  complete  conva- 
lescence by  the  patient  at  the  dispensary  or  to  the  social  service  worker 
weeks  and  months  later,  the  path  of  the  patient  has  been  followed  and  the 
quality  of  attention  accorded  him  has  been  scrutinized. 

While  estimates  of  the  hospital  needs  of  a  community  will  vary  with  the 
education  of  people  in  the  possibilities  and  advantages  of  hospital  care  for 
their  own  particular  variety  or  for  all  varieties  of  ills,  there  is  yet  a  basis  of 
experience,  a  pragmatic  test  of  adequacy  to  be  offered.  By  this  test  Cleve- 
land's shortage  of  beds  is  manifest.  The  remedy  is,  in  the  first  place,  ade- 
quate buildings  and  personnel  and  disinterested  administration  of  its  great 
City  Hospital,  now  a  travesty  upon  hospital  service. 

Private  endowments  and  initiative  will,  as  far  as  one  can  see  into  the 
future,  always  be  required  and  generously  supplied  to  meet  the  call  for  hos- 
pital beds,  and  as  soon  as  the  present  apparent  extravagance  in  cost  of  con- 
struction subsides  there  will  certainly  be  undertaken  great  new  hospital 
buildings  and  expansions  of  the  present  admirable  ones,  all  justly  held  in 
affectionate  regard  by  a  grateful  public.  The  shortage  of  dispensary  service 
in  Cleveland,  as  compared  with  service  in  other  leading  cities,  constitutes 
another  limitation  of  medical  care  for  a  considerable  proportion  of  the  popu- 
lation and  for  the  facilities  for  consultation  and  diagnosis  available  to  the 
medical  profession. 

If  one  need  beyond  that  of  more  beds  for  acute  general  hospital  patients 
is  to  be  mentioned,  it  must  be  the  lack  of  convalescent  facilities.  This  is  a 
typical  shortcoming  of  American  cities  the  meeting  of  which  will  go  far  to 
abate  many  of  the  present  troubles  of  hospital  administrators  and  the  pro- 
fessional staffs,  and  at  the  same  time  complete  the  now  unfinished  work  so 
well  begun  in  the  hospitals  themselves. 


34  Hospital  and  Health  Purvey 

There  is  no  part  of  the  present  report  which  is  so  certain  to  appeal  to  a 
broad  public  as  this  section  on  Hospitals  and  Dispensaries.  The  public 
that  is  served,  the  public  that  contributes  for  the  support  of  hospitals,  the 
responsible  trustees  and  their  representatives,  the  hospital  superintendents, 
the  professions  (medical,  nursing,  dental,  pharmacy)  in  the  field  of  education 
and  service,  the  health  officers  and  the  private  health  agencies,  all  have  an 
interest  in  the  results  of  this  study  and  the  recommendations  presented. 

Although  individual  reports  to  the  trustees  of  the  several  hospitals  have 
already  been  presented  to  them,  the  general  hospital  situation  as  described 
will  add  to  the  understanding  of  each  in  the  solution  of  their  separate  and 
particular  problems. 

What  follows  is  for  the  convenience  of  students  of  sociology,  a  sketch  of 
methods  used,  a  list  of  analyses  of  kindred  subjects  made  by  other  survey- 
ors, and  the  inevitable  index  of  subjects  to  save  the  reader's  time. 

Part  XI.  contains  what  may  be  likened  to  the  description  of  technic  in  a 
physician's  approach  to  his  patient,  the  items  to  be  included  in  his  history 
and  physical  examination,  etc.  Although  lists  of  publications  dealing  with 
surveys  have  been  issued  by  libraries  it  has  seemed  wise  to  include  here  such 
as  have  been  found  useful  to  our  present  purpose  or  have  in  one  way  or 
another  been  levied  upon  for  information  or  comparison. 


Introduction  35 


Summary  of  Recommendations 

THE  Cleveland  Hospital  Council  specifically  requested  that  detailed  and 
definite  recommendations  for  action  be  prepared  by  those  responsible 
for  the  Survey.  In  the  course  of  the  following  chapters  the  discovery  of 
facts  and  the  discussion  of  policies  have  been  directed  towards  as  definite  a 
solution  for  each  difficulty  or  inadequacy  as  was  found  practicable.  At  the 
end  of  each  chapter  there  has  been  placed  a  summary  of  recommendations,, 
subject  by  subject.  The  full  extent  of  the  program  which  is  conceived  and 
the  bearing  that  such  a  program  of  medical  and  social  endeavor  has  upon  the 
fabric  of  government  and  upon  organized  private  effort  can  best  be  seen  by 
an  assembly  of  the  various  recommendations  in  certain  main  groups.  An- 
alysis of  those  presented  in  the  text  shows  that  they  fall  logically  under 
four  headings. 

The  first  group  deals  with  laws,  both  state  and  local  (that  is,  as  passed 
by  the  state  legislature  and  affecting  Cleveland,  either  directly  or  through 
charter  provisions,  and  ordinances  enacted  by  the  legislative  body  of  the  city 
— the  City  Council).  The  variety  of  changes  thought  desirable  to  suggest 
is  such  that  it  is  believed  nothing  short  of  an  organized  effort  in  the  interest 
of  this  supplementary  program  of  social  legislation  will  suffice  to  obtain  con- 
sideration by  the  state  and  local  law  makers.  It  is,  therefore,  recommended 
that  the  Welfare  Federation  request  the  volunteer  services  of  a  committee 
of  lawyers  and  public  officers  of  the  State  Legislature  and  the  City  Council 
to  consider  and  act  upon  the  recommendations  of  the  Survey  dealing  with 
amendments  or  additions  to  the  laws. 

A  study  of  the  recommendations  under  the  various  chapters  shows 
that  suggestions  are  made  which  affect  the  State  Child  Labor  Law,  the 
State  School  Code  and  the  local  city  ordinance  dealing  with  street  trades,  in 
the  interest  of  the  health  of  children;  the  Civil  Code  and  Medical  Practice 
Act  in  dealing  with  irresponsible  and  unlicensed  medical  and  dental  prac- 
titioners, the  annual  registry  of  dentists,  the  licensing  of  dental  hygienists 
and  nurse  attendants  and  of  various  state  statutes  dealing  with  the  sale  of 
drugs  elsewhere  than  in  drug  stores  and  the  privilege  of  purchasing  tax-free 
alcohol  by  retail  druggists;  the  Injunction  and  Abatement  Law,  the  laws 
dealing  with  prostitutes  in  the  interest  of  control  of  venereal  diseases;  the 
laws  covering  the  diagnosis  and  treatment  of  mentally  defective  persons  who 
come  in  contact  with  the  courts  and  the  laws  dealing  with  the  licensing  and 
supervision  of  hotels,  both  of  which  affect  in  some  measure  the  social  program 
for  venereal  disease  control;  a  law  providing  for  supervision  and  licensing 
of  hospitals  under  the  State  Department  of  Health;  the  modification  of 
the  city  charter  to  permit  of  the  appointment  of  a  Board  of  Trustees  to  be 
responsible  for  the  administration  of  the  City  Hospital;  the  enactment  of  a 
revised  Sanitary  Code  for  the  city  of  Cleveland. 

The  second  and  very  extensive  group  of  recommendations  deals  with  the 
manner  of  conduct  of  existing  departments  of  state  and  city  goverment  and 
with  the  additional  activities  which  it  is  thought  suitable  or  necessary  for 
them  to  undertake.  Many  of  the  recommendations  presented  have  been 
discussed  in  detail  with  the  administrative  officers,  particularly  of  the  city 


36  Hospital  and  Health  Survey 

government,  and  in  some  instances  with  those  of  state  departments  within 
whose  power  it  is  to  modify  procedure  or  activities  to  meet  the  suggestions 
made.  Many  of  the  recommendations  cannot,  however,  be  carried  out 
without  generous  increase  of  appropriations  and  some  must  wait  for  authority 
from  elected  executive  officers  by  whom  the  administrators  are  appointed  and 
from  whom  they  have  received  their  authority. 

It  may  be  said  in  general  that  there  is  ample  authority  but  insufficient 
appropriation  and  personnel  to  carry  out  the  wishes  which  the  voters  and 
legislators  evidently  had  in  mind  in  framing  the  laws.  The  recommenda- 
tions, as  they  affect  the  state  government,  propose  an  adequate  inspection 
service  to  protect  the  licensed  practitioners  of  the  various  medical  and 
associated  professions;  adequate  inspection  service  for  the  institutions  of 
the  state  hospitals,  institutions  for  children  and  others;  adequate  inspection 
service  to  protect  women  and  children  in  industry  and  to  enforce  the  child 
labor  law;  and  the  transfer  of  the  responsibility  for  supervision  of  food  hand- 
lers in  restaurants  from  the  Department  of  the  State  Fire  Marshal  to  the 
State  Department  of  Health. 

General  recommendations  dealing  with  the  city  government  include 
approval  of  the  activities  of  the  City  Plan  Commission;  the  investigation 
of  sewage  collection,  treatment  and  disposal;  investigation  of  the  methods 
of  collection  and  disposal  of  rubbish  and  garbage;  a  suggestion  that  the 
sum  of  $1,000,000  be  provided  annually  for  the  next  fifteen  years  for  sewer 
construction.  The  departments  of  the  city  government  which  the  recom- 
mendations particularly  affect  are  the  Department  of  Public  Welfare,  the 
Board  of  Education,  the  Department  of  Public  Service  and  the  Department 
of  Public  Safety,  under  all  of  which  departments  there  are  activities  which 
deal  more  or  less  intimately  with  some  or  all  phases  of  health  protection  and 
care  of  the  sick.  It  is  believed  that  the  most  effective  way  of  obtaining  im- 
provements of  service  or  extensions  of  service  as  suggested  in  the  recommenda- 
tions bearing  upon  the  departments  of  city  government  will  be  by  organizing 
a  Public  Health  Association  in  the  city  of  Cleveland,  as  proposed  in  the 
Introductory  Chapter  of  Part  II.,  and  it  is  particularly  suggested  that  one  of 
the  most  important  activities  of  such  an  association  would  be  to  maintain 
friendly  and  cooperative  contact  with  the  officers  of  the  city  government 
so  that  they  may  feel  the  support  of  the  citizens,  may  get  the  benefit  of  criti- 
cal comment  upon  their  activities  and  will  be  stimulated  to  their  very  best 
effort  by  the  knowledge  that  their  activities  are  being  analyzed  and  tested 
by  high  standards.  By  those  means  of  education  properly  included  in  the 
terms  propaganda  and  publicity  such  an  association  would  materially  aid 
the  officers  of  public  departments  to  obtain  adequate  funds  from  the  appro- 
priating body,  the  Board  of  Control,  needed  to  carry  on  the  activities  recom- 
mended and  desired  by  the  tax-payers.  The  extent  and  detail  of  the  recom- 
mendations are  too  great  to  lend  themselves  to  any  summary  in  this  place 
and  the  reader  is  referred  to  the  summaries  of  recommendations,  especially 
at  the  ends  of  chapters  dealing  with  public  health  services,  child  welfare, 
venereal  diseases,  tuberculosis  and  mental  hygiene. 

The  third  group  of  recommendations  deals  with  the  private  agencies. 
In  almost  all  instances  the  recommendations  as  printed  in  the  report  have 


Introduction  37 

been  discussed  with  the  officers  or  governing  bodies  of  the  private  agencies 
which  contribute  to  health  protection  and  the  care  of  the  sick.  In  the  case 
of  all  the  hospitals,  in  addition  to  the  recommendations  here  included,  a 
special  report,  with  detailed  treatment  of  all  the  aspects  of  hospital  work, 
has  been  prepared  and  submitted  to  the  trustees  of  each  of  the  hospitals  in 
conference  and  by  written  statement.  In  the  same  way  those  matters 
bearing  upon  educational  policies  and  practices  in  the  various  professional 
schools  for  medicine  and  the  associated  professions  in  Western  Reserve 
University  have  been  presented  by  word  of  mouth  and  in  written  report  to 
the  University  authorities. 

The  several  coordinating  agencies,  such  as  the  Welfare  Federation,  the 
Cleveland  Hospital  Council,  the  Academy  of  Medicine,  the  Association  for 
the  Crippled  and  Disabled,  the  Central  Nursing  Committee,  the  Kinder- 
garten and  Day  Nursery  Association,  have  special  responsibilities  in  further- 
ing the  recommendations  which  deal  with  their  component  organizations  or 
personnel.  Similarly,  the  Chamber  of  Commerce,  the  Rotary  Club  and  the 
Cleveland  Advertising  Club  have  very  broad  duties  in  support  of  all  the 
movements  which  contribute  to  the  well-being  of  the  public.  To  these  co- 
ordinating agencies,  both  those  dealing  with  professional  fields  and  those  of 
a  general  business  nature,  are  assigned  certain  obligations  in  the  recom- 
mendations as  presented. 

Upon  industry  a  considerable  burden  is  placed  in  suggestions  that  it  meet 
the  modern  conception  of  responsibility  to  the  employes  by  organizing  for 
their  protection  against  industrial  hazards,  and  for  their  medical  care,  the 
professional  and  community  resources  which  are  mentioned  in  considerable 
detail  in  the  section  on  industry  in  Cleveland.  In  addition  to  certain  recom- 
mendations which  deal  with  the  activities  of  the  Anti-Tuberculosis  League 
the  recommendation  is  made  that  a  number  of  new  and  coordinated  public 
health  agencies,  based  on  private  initiative  and  support,  should  be  established. 

Under  the  fourth  heading  would  fall  naturally  the  recommendations  for 
new  activities.  Among  these  the  most  important  is  the  Cleveland  Public 
Health  Association  above  referred  to,  planned  as  a  parent  and  centralizing 
force  in  all  private  health  activities  for  the  city,  with  section  activities  to  deal 
with  child  welfare  and  its  subdivisions  —  prenatal,  pre-school,  school  child 
and  child  labor  features — venereal  diseases,  tuberculosis,  cripples,  obstetrical 
care,  and  so  forth.  Two  of  the  fields  of  preventive  medicine  are  not  as  yet 
occupied  by  any  private  effort  in  Cleveland;  the  first,  the  field  of  prevention 
and  relief  of  heart  disease,  and  the  second  the  prevention  and  cure  of  cancer. 
Both  the  education  and  the  technical  professional  sides  of  these  two  prob- 
lems need  the  same  kind  of  organized  support  that  has  been  provided  to 
develop  public  services  in  the  fields  of  tuberculosis,  venereal  disease  and  child 
hygiene. 

Two  new  institutional  activities  for  which  the  sick  of  Cleveland  are  now 
really  suffering  are:  a  well  organized  central  dispensary  and  provision  for 
convalescent  care  outside  of  the  general  hospitals  and  under  suitable  con- 
ditions of  space  and  occupation. 


38  Hospital  and  Health  Survey 


In  offering  such  a  series  of  comprehensive  suggestions  it  is  recognized 
that  no  community  however  willing,  however  wealthy,  however  well  edu- 
cated in  its  social  responsibilities  could  put  into  effect  all  the  proposals, 
without  a  sacrifice  of  much  that  is  good  in  the  existing  agencies  and  institu- 
tions, which  must  be  used  to  build  upon,  and  not  be  destroyed  in  the  process 
of  reconstruction.  That  all  the  recommendations  can  be  made,  even  at  the 
very  considerable  expense  which  this  will  involve,  is  the  confident  belief  of 
the  staff  of  the  Survey,  based  upon  its  contact  and  experience  with  the  citi- 
zens of  Cleveland  in  all  walks  of  life  who  have  been  a  continuous,  source  of 
encouragement  and  inspiration  to  the  investigators  throughout  the  past  year. 
When  the  program  here  presented  has  been  carried  out  it  will  be  found  that, 
in  terms  of  human  lives  ajid  happiness,  Cleveland  has  greatly  increased  vital 
assets  although  its  financial  liabilities  may  be  found  to  have  been  increased 
beyond  the  point  to  which  communities  are  now  accustomed  to  spend  the 
money  of  either  the  tax-payer  or  the  private  contributor. 


CITY  OF   CLEVELAND 


SHOWING    STREET    CAR    TRAFFIC 
AND 

DISTRIBUTION  OF  POPULATION 


Courtesy  Board  of  Rapid  Transit  Commissioner* 


WV  "Uilil"\"iv\'r>i<i\       Indicates  Health  District  Boundaries 


General  Environment  and  Sanitation 

Population  ana  Area 

CLEVELAND,  founded  in  1796,  incorporated  as  a  village  in  1815,  and 
chartered  as  a  city  in  1836,  is  the  largest  city  of  Ohio  and  the  fifth  in 
size  in  the  L'nited  States,  its  population  in  January,  1920,  being  796,836. 
New  York,  Philadelphia,  Chicago  and  Detroit  are  larger.  With  1,075 
people  in  1830,  Cleveland  grew  steadily  but  slowly  until  1872,  when,  from  a 
population  of  103,033,  it  began  a  more  rapid  development.  The  city  and 
its  immediate  suburbs  have  very  close  to  1,000,000  population  now.  The 
favorable  commercial  and  economic  conditions  existing  in  Cleveland,  to- 
gether with  its'  advantageous  geographical  location,  'combined  with  its  past 
consistent  record  for  steady  growth,  warrant  the  belief  that  within  the  next 
20  to  25  years  a  population  of  one  and  a  half  or  two  million  people  may  be 
expected. 

The  characteristic  of  steady  growth  in  Cleveland  is  probably  due  largely 
to  the  diversity  of  business  and  manufacturing  enterprises  of  the  city  and  their 
relative  stability.  The  fact  that  the  city  is  favorably  situated  on  both 
water  and  rail  routes  of  national  importance  with  short  haul  on  raw  mate- 
rials and  that  it  is  also  centrally  located  for  direct  distribution  of  manufac- 
tured products  to  all  parts  of  the  country,  has  undoubtedly  been  the  basis  of 
this  steadiness  of  growth. 

There  is  a  very  marked  separation  of  the  residential  districts  into  groups, 
the  separation  being  caused  primarily  by  the  Cuyahoga  River  and  the 
valleys  and  hills  typical  of  the  area  covered  by  the  city,  and,  secondarily,  by 
the  grouping  of  population  around  or  near  the  factories  which  are  located 
principally  along  the  steam  railway  lines. 

A  vigourous,  educated,  ambitious  type  of  early  settlers  gave  a  distinctive 
character  to  Cleveland's  early  existence,  and  the  junction  of  coal  and  iron 
with  a  favorable  harbor  and  excellent  rail  and  water  transport,  combined 
with  a  rich  farming  country  and  fortunate  climate,  have  brought  to  Cleve- 
land the  industrious  immigrant  and  the  laborer  from  our  Southern  states 
until  it  now  represents  as  typical  an  American  city  as  can  be  found,  with  the 
excellencies  and  shortcomings  in  government,  living  standards  and  accom- 
plishments which  alternately  make  us  proud  and  mortified. 

There  is  no  good  reason  to  believe  that  the  age  and  race  composition  of 
Cleveland  have  been  materially  modified  in  the  past  ten  years  unless  it  be 
by  the  addition  of  large  numbers  of  Negroes.  This  has  been  a  folk  movement 
and  no  important  preponderance  of  males  has  been  observed,  the  families 
following  soon  after  the  arrival  of  the  wage  earner. 


40 


Hospital  and  Health  Survey 


Environment  and  Sanitation  41 


The  1910  census  report  shows  the  following  age  and  race  distribution  for 
Cleveland  and  for  the  total  urban  population  of  the  Registration  Area  of 
the  United  States. 

All  Classes  Native  White  Foreign-Born  White        Negro 

Native  Foreign  or 


Ages 

Cleve- 
land 

U.  S. 

Urban 

Parentage 

Cleve-        U.  S. 

land        Urban 

Mixed  Parentage 

Cleve-          U.  S. 

land          Urban 

Cleve- 
land 

U.  S. 

Urban 

Cleve- 
land 

U.  S. 
Urban 

All 

100% 

100% 

23.6% 

41.6% 

39.9% 

28.9% 

34.9% 

22.6% 

1-5% 

6.3^ 

Under  5 

11.1 

9.8 

3.3 

4.7 

7.4 

4.3 

.29 

2 

.09 

.5 

5—14 

17.4 

17.3 

4.8 

8.2 

10.3 

6.9 

2.0 

1 

16 

1.1 

15—24 

20.5 

20.0 

4.75 

8  6 

9.2 

6  3 

6.2 

3.9 

28 

1.4 

25 — 44 

34.4 

33.2 

7.3 

12.5 

9.9 

8.0 

16.5 

10.2 

7 

2.3 

45—64 

13.4 

15.2 

2.6 

5.8 

2   8 

3   1 

7.7 

5.4 

2 

8 

55  and  over 

3  0 

4  0 

6 

1.8 

2 

3 

2.0 

1.7 

03 

2 

For  original  nationality  of  Cleveland  residents  and  further  details  of 
population,  for  the  city  as  a  whole  and  by  districts,  the  reader  is  referred  to 
the  forthcoming  data  of  the  1920  census,  which  should  be  published  soon 
after  the  publication  of  this  report.  Re-publishing  here  the  facts  of  the 
1910  census  seems  superfluous. 

Neither  the  Negro  nor  the  Irish  are  present  in  Cleveland  in  sufficient 
numbers  to  materially  affect  their  particular  racial  susceptibility  to  pul- 
monary tuberculosis  and  other  diseases  of  the  respiratory  tract,  or  the  mor- 
bidity or  mortality  of  the  city. 

The  following,  compiled  from  the  best  information  obtainable  of  the 
population  and  area  of  this  district  for  the  period  from  1900  to  1918,  inclu- 
sive, was  made  up  before  the  1920  census  figures  were  available  and  indi- 
cates an  overestimation  of  population: 

Population  of  Cleveland  and  Suburbs 

City  Within  Population  City  Population 


Co  port  te  per  and 


per 


Limits  Acre  Suburbs  Acre 

1900 ...381,800  17.5  421,834  5.5 

1905 ...459,500  17.4  514/205  6.7 

1910 .....559,900  19.0  630,577  8.2 

1915 734,000  21.8  836,089  10.9 

1918 855,000  22.8  971,380  12.7 

The  population  per  acre  in  the  above  table  in  the  case  of  corporate  Cleve- 
land is  based  upon  the  area  within  the  corporate  limits  as  of  each  date, 
being  34  square  miles  in  1900  and  .58.70  square  miles  in  1918.     The  popula- 


42  Hospital  and  Health  Survey 


tion  per  acre  for  the  city  and  suburbs  in  the  right-hand  column  of  the  same 
table  is  calculated  upon  the  basis  of  119.1  square  miles  as  the  area  occupied 
by  the  971,380  estimated  population  of  1918. 

Politically,  the  city  is  divided  into  26  wards  and  488  precincts,  but  since 
there  are  no 'continuous  or  reliable  vital  statistics  available  (i.e.,  births, 
deaths  or  sicknessj  by  these  subdivisions,  the  only  subdivisions  which  will 
be  used  in  this  report  will  be  the  eight  health  districts  as  established  in  1917, 
for  which  much  useful  information  has  been  recorded.  It  is  thought  to  be  a 
matter  of  much  importance  to  future  municipal  government,  especially  in 
the  field  of  public  health,  and  for  the  private  health  welfare,  and  relief  agen- 
cies of  the  city  that  the  census  units  or  forty-acre  tracts,  or  as  they  are  called 
in  other  cities,  sanitary  areas,  used  by  the  Federal  Census  Bureau  for  the 
tabulation  of  population  data  in  1910  and  1920,  be  made  the  basis  of  all 
administrative  areas  of  the  city,  and  that  both  public  and  private  agencies 
in  arranging  their  field  services  use  districts  which  include  multiples  of  the 
census  units.  In  this  way  the  cumulative  value  of  orderly  collection  of  facts 
will  soon  contribute  to  the  development  of  logical  programs  of  action.  x\t 
present  there  is  little  or  no  data  available  except  by  the  city  as  a  whole,  a 
unit  too  large  for  the  detailed  analysis  now  required  in  intensive  public- 
health  work.  A  map  showing  the  sanitarv  areas  will  be  found  in  Part  II. 
(Fig.  II.) 

The  densest  quarter-mile  square  sections  are  found  in  wards  11  and  12, 
south  of  Euclid  and  east  of  14th  Street,  where  the  population  ranges  from  90 
to  95  persons  per  acre.  North  of  Euclid  and  east  of  55th  Street  there  are  dis- 
tricts ranging  from  50  to  55  persons  per  acre  and  on  the  West  Side,  in  the 
4th  and  5th  wards,  the  population  ranges  from  50  to  75  persons  per  acre  for 
relatively  small  districts.  It  will  be  seen,  therefore,  that  these  maximum 
densities  are  far  below  what  are  termed  tenement  districts  in  New  York, 
Chicago  and  Philadelphia,  where  250  persons  per  acre  are  quite  frequently 
found  over  considerable  areas.  In  limited  districts  as  many  as  640  people 
per  acre  are  found  in  the  dense  East  Side  sections  of  Manhattan  Borough  of 
the  city  of  New  York. 

In  Cleveland,  therefore,  we  have  no  acutely  crowded  districts  and  the 
general  average  population  per  acre  is  about  18  as  against  20  for  the  city 
of  Chicago,  19  for  the  citv  of  Detroit  and  164  for  Manhattan  Island  in  New 
York  City. 

Greater  New  York  for  the  whole  metropolitan  district  has  about  26  per- 
sons per  acre  as  against  13  persons  per  acre  for  a  similar  territory  in  Cleve- 
land. 

The  fact  that  the  city  has  developed  east  and  southeast  of  the  central 
retail  and  business  districts  to  a  greater  degree  than  west  and  southwest  is 
accounted  for  largely  by  former  absence  of  convenient  bridges  across  the 
valley  of  the  Cuyahoga  River  and  to  lack  of  development  of  the  water  and 
sewage  systems  in  the  southwest  side  of  the  city.     The  general  characteristic 


Environment  and  Sanitation  43 

of  Cleveland's  residential  districts  is  that  of  detached  one  and  two-family 
residences  and  the  result  of  using  this  form  of  homes  is  to  create  a  city  with 
relatively  low  population  densities  and  consequent  extended  areas. 

A  fact  of  some  possible  importance  in  health  development  and  main- 
tenance of  the  industrial  workers  of  Cleveland  is  that  a  larger  portion  of  them 
live  within  easy  daily  walking  distance  of  their  work  than  is  the  case  in 
Chicago  or  Detroit.  To  quote  from  the  report  of  the  Rapid  Transit  Com- 
mission, "A  general  inquiry  made  by  us  into  the  question  of  employment 
districts  and  residential  locations,  develops  the  fact  that  there  is  an  unusu- 
ally large  residential  grouping  of  factory  workers  about  their  places  of 
employment  throughout  the  city  of  Cleveland.  Thus,  two  groups  of  fac- 
tories on  the  West  Side  have  35%  and  50%,  respectively  of  their  employes 
within  walking  distance.  On  the  East  Side  a  factory  group  in  the  79th  Street 
district  has  60%  walking  employes  and  another  in  the  same  district  has  75% 
walkers.  Taking  the  whole  East  Side  group  of  factories  apparently  only 
15%  to  20%  of  the  employes  live  on  the  West  Side  of  the  city. 

This  condition  is  unusual  compared  with  other  large  cities.  In  Detroit 
an  exhaustive  canvass  of  the  factories  showed  only  one  group  with  75%  of 
walkers,  the  balance  of  factories  showing  from  16  %  to  40%  of  their  employes 
walking  and  the  average  being  only  28.2%  for  the  city.  In  Chicago  the  situa- 
tion was  similar,  the  average  walkers  out  of  350,000  factory  employes  being- 
only  24.4%  and  any  group  showing  over  40%  was  unusual.  Cleveland  has 
48%  of  walkers." 

The  report  on  Housing  Conditions  of  War  Workers  in  Cleveland  made 
by  the  Committee  on  Housing  and  Sanitation  of  the  Cleveland  Chamber  of 
Commerce  and  by  the  United  States  Home  Registration  Service  in  October, 
1918,  states: 

"TIME  SPENT  IN  GOING  TO  WORK" 

"Out  of  a  total  of  21,832  wage  earners,  10,364,  or  48%,  walk  to  and 
from  their  work.  This  proximity  of  industry  to  the  home  is  desirable,  and, 
in  a  city  like  Cleveland,  with  its  factories  well  distributed  and  accessible  to 
residential  sections,  it  ought  not  to  be  impossible.  Out  of  the  number  who 
walk,  945  spend  from  30  to  60  minutes  walking  to  work  or  from  one  to  two 
hours  a  day  in  going  to  and  coming  from  work.  *****  52%  of  the 
wage  earners  ride  to  their  work.  Of  this  number  5,059  spend  from  30  to  60 
minutes  riding  one  way,  or  from  one  to  two  hours  going  to  and  coming  from 
work  each  day.  1,411  spend  more  than  one  hour  going  to  work,  or  more 
than  two  hours  going  ar.  d  coming  from  work  each  day.  More  than  300 
spend  more  than  three  hours  a  day  in  going  to  and  coming  from  work  each 
day.  These  latter  figures  indicate  a  waste  of  time  and  energy  on  the  part 
of  the  worker  that  must  be  detrimental  to  his  efficiency  as  a  worker." 

For  reference  there  is  included  here  a  table  of  population  density  per 
square  mile  and  per  acre  for  Cleveland  and  its  suburbs  included  within 
Cuyahoga  County.  We  wish  here  to  acknowledge  our  debt  to  the  Board  of 
Rapid  Transit  Commissioners  for  the  privilege  of  quoting  freely  from  their 
report  in  the  foregoing  pages  and  for  the  use  of  the  two  charts. 


44 


Hospital  and  Health  Survey 


Population  and  Area  of  Cleveland  and  Subdivisions  in 
Cuyahoga  County — 1918 

Report  to  Board  of  Rapid  Transit  Commissioners 


Corporate  Name 

Cleveland  East  Side 

Cleveland  West  Side 

East  Cleveland 

Lakewood.. 

Bay  Village. 

Bedford  Township 

Bedford  Village 

Beechwood... _. 

Berea 

Bratenahl 

Brecksville  Township 

Brookpark  Village 

Brooklyn  Township 

Brooklyn  Heights  Village 

Chagrin  Falls 

Chagrin  Falls  Township 

Cleveland  Heights 

Claribel .. 

Dover  Village 

East  View 

Euclidville 

Euclid  Village ., 

Fairview  Village 

Glenwillow 

Goldwood  Township 

Idlewood 

Independence  Township 

Independence  Village 

Linndale  

Maple  Heights  Village 

Mayfield  Township 

Middleburg  Township 

Newburgh  Heights  Village, 

including 

Cuyahoga  Heights  Village 


Population 
Estimated 

Area  Sq. 

Miles 

Population 
Per  Sq.  Mile 

Populatio 
Per  Acre 

607,400 

39.4 

15 

,416.2 

24.1 

247,600 

19.3 

12 

,829.0 

20.0 

25,000 

3.0 

8 

,333.3 

13   0 

42,800 

5.4 

7 

,926.0 

12.4 

608 

4.8 

126.5 

0.2 

1,620 

18.7 

86.7 

0.1 

2,796 

2.3 

1 

,215.1 

1.9 

325 

4.5 

72.3 

0.1 

3,500 

1.3 

2 

,692.3 

4.2 

1,252 

1.0 

1 

,252.0 

2.0 

1 ,  063 

28.0 

38.1 

0.1 

896 

10.2 

87.8 

0.1 

855 

4.6 

185.6 

0.3 

592 

2.8 

211.4 

0.3 

2,164 

2.5 

865.6 

1.3 

300 

4.8 

62.6 

0.1 

15.,  000 

7.6 

1 

,973.7 

3.1 

1,593 

3.5 

455.1 

0.7 

1,800 

16.5 

109.0 

0.2 

422 

2.2 

191.8 

0.3 

1,500 

2.8 

535.7 

0.8 

3,236 

11.4 

283.8 

0  4 

600 

3.5 

171.3 

0.3 

250 

2.8 

89.5 

0.1 

498 

2.4 

207.9 

0.3 

90 

1.9 

47.3 

0.1 

329 

5   0 

65.8 

0.1 

1.280 

10  0 

128.0 

0.2 

366 

0.1 

3 

, 660 . 0 

5.7 

2,200 

4.5 

488.9 

0.8 

1,160 

23.8 

48.8 

0.1 

1.838 

11.7 

157  3 

0.2 

3.300 


3   8 


6 . 600   0 


10.3 


Environment  and  Sanitation  45 


North  Olmsted  Village- 
North  Randall  Village.. 

Olmsted  Township 

Olmsted  Falls  Village 

Orange  Township 

Parma  Township 

Parma  Heights  Village 

Rocky  River ..... 

Royalton  Township 

Shaker  Heights  Village. 

South  Euclid... 

South  Newburgh 

Solon  Township 

Strongsville 

Warrensville 

West  Park  


1,232 

11.9 

103.5 

0.2 

70 

0.5 

140.0 

0.2 

1,880 

15.6 

120.5 

0.2 

560 

0.8 

700.0 

1.1 

860 

23.5 

36.6 

0.1 

1,866 

20.4 

89.8 

0.1 

355 

3.9 

91.2 

0.1 

1,855 

4.3 

431.4 

0.7 

1,132 

25.5 

44.5 

0.1 

3,000 

4.4 

681.8 

1.1 

2,400 

5.8 

413.8 

0.6 

2,400 

13.7 

175.2 

0.3 

990 

20.0 

49.5 

0.1 

1,540 

24.5 

62.9 

0.1 

391 

10.3 

38.0 

0.1 

8,000 

12.9 

620.1 

1.0 

Total... 1,002,728  464.1 


Average 2161  0  3.376 


46  Hospital  and  Health  Survey 

Topography   and  Climate 

CLEVELAND  occupies  an  area  of  58.7  square  miles,  extending  for  about 
20  miles  along  the  southern  shore  of  Lake  Erie  and  situated  on  both 
sides  of  the  Cuyahoga  River  where  it  empties  into  Lake  Erie.     Its 
altitude  is  6,00  feet  above  sea  level. 

The  gravel,  sand,  clay  and  shale  which  compose  the  various  benches  and 
valleys  of  the  glacial  drift  deposit  which  makes  the  plateau  upon  which  the 
city  is  built,  vary  greatly  in  their  surface  drainage  qualities  from  what  may 
be  called  perfect  subsoil  .drainage  in  the  sand  and  gravel  regions,  to  imper- 
meable clay  and  a  high  ground-water  level,  for  instance  in  the  Collinwood 
region.  The  surrounding  country  is  rolling  hills  with  extensive  woods 
and  clear  open  farms.  Deep  gullies  and  valleys  cut  across  the  plateau  in 
many  places  within  the  city  limits. 

The  city  is  divided  for  political  purposes  into  26  wards  and  488  pre- 
cincts. 

For  purposes  of  the  Federal  Census  the  city  is  divided  into  131  Sanitary 
Areas,  as  indicated  in  Fig.  II.,  Part  II. 

For  convenience  in  local  health  administration  the  city  is  divided  into 
eight  health  districts,  as  indicated  on  the  frontispiece  map  of  this  part  show- 
ing distribution  of  population. 

The  watershed  is,  of  course,  solely  into  Lake  Erie.  The  only  important 
relationship  between  the  geological  formation  and  the  health  of  the  people 
is  the  same  that  is  noticed  widely  in  the  lake  region  where  the  water  supply 
comes  wholly  or  in  large  measure  from  the  glacial  drift;  namely,  the  preva- 
lence of  endemic  goitre,  which  can  be  found  congenitally  in  young  children 
and  widespread  among  girls  and  women  who  have  lived  continuously  in  this 
general  area  for  many  years. 

Climate 

The  data  obtained  from  the  offices  of  the  United  States  Weather  Bureau 
in  Cleveland  show  a  mean  temperature  of  26.8°  F.  for  January  and  of  70.1°  F. 
for  July  (1871-1918)  and  for  the  year  49.0°  F.  The  mean  daily  range  of 
temperature  is  14.7°  F.  Sudden  changes  are  not  uncommon  in  the  fall  and 
winter  with  northwest  winds. 

Temperature  extremes  have  varied  in  the  past  48  years  from  -17°  F.  in 
January, — 16°  F.  in  February,  4°  F.  and  zero  F.  in  November  and  12°  F. 
in  December  to  a  maximum  of  92°  F.  in  May,  96°  F.  in  June,  97°  F.  in  July, 
100°  F.  in  August  and  98°  F.  in  September. 

There  are  few  instances  where  the  temperatures  below  zero  F.  or  above 
90°  F.  were  recorded  for  more  than  four  days  consecutively. 

The  mean  annual  precipitation  at  Cleveland  since  1871  has  been  34.39 
inches,  distributed  with  remarkable  evenness  throughout  the  year. 


Environment  and  Sanitation  47 

The  mean  relative  humidity  in  Cleveland,  Buffalo  and  Detroit  at  8  a.  m. 
and  8  p.  m.  have  been  recorded  as  follows : 

8  A.M.  8  P.M. 

Cleveland  Buffalo  Detroit       Cleveland      Buffalo  Detroit 

Winter 79  77  84  75                  75  80 

Spring 76  73  76  68                  70  68 

Summer... 73  75  75  66                 69  64 

Fall 77  75  81  70                  71  71 

Year 76  71  79  70  .      75  71 

Cleveland,  as  measured  by  relative  humidity  in  the  morning,  stands 
between  Buffalo  and  Detroit,  but  according  to  relative  humidity  at  night, 
Cleveland  has  less  than  either  of  the  other  two  lake  cities. 

The  prevailing  winds  are  westerly,  which  accounts  for  the  greater  clean- 
ness of  air  and  exposed  building  surfaces  and  the  better  vegetation  on  the 
west  side  of  the  city.  The  smoke  of  the  valley  and  the  center  of  the  city 
causes  a  serious  nuisance  and  menace  to  health  most  of  the  time  well  out  to 
105th  Street  on  the  East  Side,  and  at  some  times  extending  in  an  appreciable 
curtain  offensive  to  smell  even  to  the  Heights  and  select  residence  district 
further  east.  At  the  present  rate  of  industrial  development  and  with  the 
existing  indifference  to  the  smoke  nuisance,  the  prevailing  winds  will  in  a 
few  years  make  the  fine  buildings,  Museum,  University,  etc.,  on  both  sides 
of  Wade  Park  unsightly  and  the  use  of  them  far  from  attractive.  The  aver- 
age velocity  of  the  wind  is  13.6  miles  per  hour,  a  rate  somewhat  less  than 
that  prevailing  in  New  York  City  (15.5). 

There  is  nothing  important  in  Cleveland's  climate  in  relation  to  health. 
It  is  a  moderate  northern  climate,  typical  of  the  Lake  Region,  but  without 
excessive  humidity,  precipitation,  winds  or  extremes  of  temperature,  on  the 
whole  a  good  climate,  but  its  effects  for  good  to  a  considerable  degree  offset 
by  the  changes  produced  in  the  air  and  light  by  the  constant  fall  of  smoke 
and  fumes  that  are  characteristic  of  the  city  and  are  seen  from  afar  on  ap- 
proaching the  city  by  water. 

At  a  latitude  of  41°  30'  and  longitude  81°  42',  Cleveland  is  credited  with 
a  possible  total  hours  of  sunshine  in  the  year  of  4,457.4.  By  actual  meas- 
urement Cleveland  has  in  a  year  2,367.2  hours  of  sunshine,  or  53.1%  of  the 
possible.  In  the  four  months  of  December  to  March  Cleveland  has  the  bene- 
fit of  only  34%  of  the  theoretically  possible  hours  of  sunshine.  How  much 
of  this  loss  is  due  to  the  unfavorable  conditions  of  smoke  pollution  of  the  air 
cannot  be  stated. 


48  Hospital  and  Health  Survey 

Housing 

THE  work,  the  publications,  the  influence  upon  public  opinion,  upon 
laws,  building  construction  and  sanitary  enforcement  of  ordinances, 
of  the  Committee  on  Housing  Conditions  of  the  Cleveland  Chamber 
of  Commerce  since  its  appointment  in  1912,  makes  it  unnecessary  to  treat 
of  more  thari  a  few  of  the  features  of  existing  housing  inadequacies.  The 
City  Plan  Commission,  which  is  at  present  developing  the  necessary  maps, 
the  principles  and  detailed  description  of  uses  upon  which  a  zoning  ordi- 
nance for  the  city  can  be  approved,  is  the  great  constructive  force  preparing 
to  prevent  repetition  of  past  errors  and  to  insure  an  orderly  and  safe  develop- 
ment of  building  construction  and  property  uses  for  the  future. 

In  this  interesting  American  method  of  municipal  control  of  building 
and  use  of  property,  there  is  fortunately  a  common  advantage  and  value 
appreciated  by  real  estate  interests  and  by  those  concerned  with  community 
health.  To  eliminate  or  reduce  to  the  least  practicable  minimum  the  erection 
of  tenements  is  one  of  the  objectives  to  be  desired  by  sanitarians,  because 
although  sanitary  conditions  may  be  maintained  in  premises  technically  tene- 
ments, the  lot  crowding  and  the  room  crowding  that  usually  occur  to  a  greater 
degree  in  buildings  occupied  by  three  or  more  families  than  in  single  or  two- 
family  houses,  are  found  to  be  accompanied  by  the  three  important  evidences 
of  unsuitable  living  conditions:  namely,  high  incidence  of  communicable 
disease,  high  infant  mortality  rate  and  high  general  or  crude  death  rate. 

These  three  conditions  prevail  in  Cleveland  as  they  do  in  other  cities 
where  there  is  the  greatest  density  of  population.  Where  there  is  the  greatest 
density  of  population  there  is  found  the  worst  condition  of  lot  and  room 
crowding.  The  races  found  in  the  worst  houses  in  Cleveland  are  the  Negroes, 
the  Italians,  the  Jews  and  the  foreign-born  Slavs,  Slovaks,  Lithuanians  and 
Poles.  The  poor,  those  ignorant  of  their  rights  under  the  law,  in  the  main 
the  negroes  and  the  foreign-born,  suffer  not  only  from  the  economic  disad- 
vantages from  which  they  are  emerging,  but  they  do  not  receive  that  protec- 
tion from  the  law  to  which  they  are  entitled. 

Careful  and  repeated  inspection  of  what  is  known  as  the  Hill  district,  of 
the  Woodland  district,  of  the  downtown  lodging  house  district  on  the  East 
Side,  and  of  the  so-called  Triangle  at  the  west  end  of  the  Superior  Ave- 
nue bridge,  during  the  winter  and  spring  of  1920,  disclosed  ^conditions  in 
violation  of  all  of  the  important  sections  of  the  ordinances  dealing  with 
tenements  and  sanitation  of  occupied  premises. 

It  was  often  said  by  city  employes  and  by  others  in  excuse  of  the  intol- 
erably bad  conditions  of  occupancy  in  the  Hill  region  that  this  is  all  to  be  de- 
molished in  the  course  of  railroad  improvements.  In  the  meantime  it  cer- 
tainly points  to  astonishing  indifference  on  the  part  of  the  Bureau  of  Sani- 
tation, which  is  held  responsible  for  the  enforcement  of  Articles  III.,  IV.  and 
V.  of  Section  A,  Articles  76-84  of  City  Ordinance  32186-A,  which  was  passed 
October  18,  1915,  and  in  force  January  1,  1916  that  the  conditions  reported 
below  could  exist,  and  yet  from  the  evidence  of  district  physicians,  sanitary 


Environment  and  Sanitation  49 


inspectors,  visiting  nurses  and  residents,  the  conditions  have  existed  as  re- 
ported and  found  for  many  years  past  without  any  evidence  of  effective  re- 
medial action  by  the  city  authorities  or  by  the  owners  of  the  properties. 

Field  notes  of  the  investigator  on  May  12,  1920,  follow.  These  observa- 
tions were  verified  by  a  medical  officer  in  the  city  employ,  a  physician  who 
had  had  considerable  experience  in  sanitation  and  epidemiology  in  the  army 
here  and  abroad,  and  whose  present  work  has  convinced  him  of  the  intimate 
causal  relationship  between  the  filth,  neglect,  darkness,  lack  of  ventilation 
and  crowding  found  in  the  homes,  and  the  amount  of  invalidism  among 
children  and  adults  in  these  premises. 

Berg  Street 

Garbage  piled  high,  obstructing  the  gutter  and  sidewalk.  The  pile  was 
two  feet  high,  10  feet  wide  and  16  feet  long.  Maggots  were  developing  in 
this  pile  of  garbage,  human  and  animal  excrement  and  food  waste. 

Between  Berg  and  Jerome  Court 

Yard  privies  with  broken  seats,  fecal  deposits  on  floor,  seats  and  side  of 
privies,  obstructing  drain.  Bowl  filled  with  human  waste.  (No  lights  in  any 
of  the  halls  visited  through  this  inspection  trip,  neither  fixtures  nor  tips  for 
lighting).     Had  typhoid  fever  case  here  last  year. 

Jerome  Alley 

Garbage  bins  at  707  filled  with  rotting  accumulation  of  winter.  In  the 
house,  husband  and  wife  and  six  children  in  two  rooms.  No  gas,  no  lamps; 
yard  closets,  no  water  running,  privies  have  broken  bowl  surface,  rotting 
wood  sides,  floor  and  roof,  general  distribution  of  human  and  animal  fecal 
waste. 

Between  Berg  and  Jerome  Court 

Garbage  in  mass,  acrid,  stinking,  fly  breeding. 

703  Berg  Street 

Three  rooms,  two  adults  and  three  children.  No  provision  for  lighting; 
cooking,  washing  and  sleeping  in  same  room.  In  sheds,  under  stairways, 
rabbits,  pigeons  and  chickens  breeding  and  at  large.  Privies  in  foul,  un- 
sanitary condition;  surface  and  privy  drainage  washing  upon  alley  where 
children  are  playing. 

General  Area 

Central,  Hill,  Berg  and  Commerce  down  to  the  flats.  A  mass  of  shacks 
not  fit  for  cattle  to  be  kept  in.  Spaces  between  buildings  from  six  inches 
to  two  feet  wide,  packed  with  rotting  accumulations  thrown  in  from  the 
alleys  above.  Privy  vaults  and  sink  holes  that  are  not  protected  against 
leakage  of  fecal  accumulations  to  surrounding  area,  accessible  to  children 
and  occupants  of  premises. 


.50 


Hospital  and  Health  Survey 


1.  Back  of  Berg  Stheet. 
overlooking  jerome  codet 

This  truant  boy  "gets  airay 
from  the  kids"  in  his  "reading- 
room"  at  Ike  rear  of  an  out-hoyse 

an   fSerg  Street. 


(D 


2.  Jerome  Court,  Hwmarket 
District 

Making     mud-pies     on     "  tht 
Bouleiard,"  which  some  facetious 

tenant  has  christened  Jerome 
Court.  The  children  are  playiwi 
in  and  around  an  open  privy. 


3.   »>s  Andes  .alley 


Environment  and  Sanitation 


51 

1 


4.   Vacant   Lot  on  Jerome  Court 

The  tearing  down  of  buildings  has  been 
begun  here  but  left  unfinished. 

This  lot  and  two  others  are  the  only  play- 
ground space  for  many  children  living  in 
this  district. 

5.   A    Backyard   Playground   in   Hay- 
market   District. 


52 


Hospital  and  Health  Survea 


6.  Passageway  up  'ihe  Hill  fkom  ihe 

River  Between  Tenements. 
It  is  possible  to  icalk  up  from  Canal  Road 
I  o  Andes  Alley  on  fin-  streets  through  such  pas- 
sages.   No  sunlight  can  reach  the  rooms  which 
open  of  these   passages. 
7.  Mencken  and  Hill  Streets,  Haymabket 
District 
This  view  shows  how  houses  are  built  u p  the 
East    Ninth    Street    hill   between    Mencken    and 
Hill  Streets.    JSoIhe  of  Ihe  dwellings  ore  nothing 
more  than  burrows  in  the  around.    One  can  go 
into   a   tenement   on    Mencken    Street    and   by 
means   of  rickety   stairs    wend    his   way    across 
Jerome    Court,    Berg    Street    and    out   on    Hill 
without  seeing  the  light  of  day. 


Environment  and  Sanitation 


From  observations  made  it  would  appear  that  Article  III.,  Sections  53, 
54,  55,  56-c2  and  4,  and  59,  referring  to  buildings  used  as  tenements  before 
January  1,  1916,  were  violated  on  most  of  the  premises  inspected. 

Complaints  and  reports  of  the  conditions  as  noted  above  had  been  made 
at  intervals  over  a  period  of  a  year  with  no  remedial  action  by  the  Bureau 
of  Sanitation. 

In  another  section,  where  the  excuse  of  impending  demolition  of  premises 
couldnot  be  offered,  quite  similar  conditions  were  found,  as  follows: 

Orange  Avenue,  opposite  Depot 

Broken  toilets,  garbage  accumulation  which  has  been  on  premises  since 
August,   1919. 

2003   Orange  Avenue 

Broken  toilets,  no  lights  in  hall,  alley  with  all  winter  accumulation  of 
garbage. 

2515  Orange  Avenue 

Privy  with  leaky  sewer  outlet  where  bowl  waste  discharges  into  open 
pit,  rotting  boards  on  floor  of  shanty.  Pile  of  manure  in  yard  since  August, 
1919. 

2515  Orange  Avenue,  Second  Floor 

Toilet  opening  into  the  kitchen  snd  living  room.  No  ventilation  except 
through  the  kitchen.     Dangerously  loose  flooiing.   No  lighting  in  halls. 

The  worst  conditions  were  found  in  lodging  houses.  With  the  exception 
of  the  lodging  houses  maintained  by  the  Salvation  Army,  which  complied 
with  legal  requirements  and  presented  a  picture  of  order  and  cleanliness, 
the  lodging  houses  in  Cleveland,  including  the  one  maintained  by  the  New 
York  Central  Railroad  in  the  basement  of  the  Orange  Avenue  Freight  depot, 
violated  all  reasonable  provisions  for  sanitary  living  and  disease  prevention. 
Among  the  most  important  nuisances  found  were  inadequate  light  and  ventil- 
lation,  old,  soiled,  stained  bed  covering,  filthy  floors,  overcrowding,  lack  of 
space  between  bunks,  etc.  The  licenses  issued  by  the  State  Fire  Marshal  at 
Columbus,  Ohio,  are  obtained  without  compliance  with  reasonable  standards 
of  cleanliness.  There  is  no  routine  periodical  inspection  of  lodging  houses 
by  state  or  city  authorities.  The  cheapest  lodging  houses  operated  in  the 
densest  areas  of  New  York's  lower  East  Side  shine  by  comparison  with 
Cleveland's  "flop-houses,"  which  are  a  disgrace. 

In  response  to  the  frequent  specific  complaints  by  the  district  physicians 
of  unsanitary  conditions  in  lodging  houses,  the  Bureau  of  Sanitation  offers 
the  excuse  that  there  is  no  authority  under  the  law  to  abate  the  nuisances 
described. 

The  following  extracts  from  notes  of  the  investigator  give  a  typical  pic- 
ture of  Cleveland's  lodging  houses,  the  clean  and  the  filthy: 


54  Hospital  and  Health  Survey 


Salvation  Army  Citadel 

Has  provision  for  166  men,  each  in  single  partitioned  rooms,  the  parti- 
tions going  to  within  two  feet  of  the  ceiling,  the  space  above  being  divided 
by  an  iron  grill.  Each  room  has  48  feet  of  floor  space  and  480  cubic  feet 
of  air  sA  ace.  Toilet  seats  clogged  and  foul  because  of  use  oi  toilet  paper  instead 
of  towels  for  drying  hands  in  the  wash  places.  Premises  otherwise  clean, 
with  clean  linen  on  beds,  clean  towels  supplied  each  night.  License  to 
operate  obtained  from  the  Department  of  State  Fire  Marshal,  at  Columbus, 
$15.00  a  year.  Original  inspection  of  premises  is  made  by  representative 
from  Columbus.  No  re-inspection.  Occasionally  visited  by  sanitary  officer 
of  Cleveland  Health  Division. 

Metropole 

Another  Salvation  Army  lodging  house  where  a  license  of  $20.00  a  year 
is  paid,  having  accommodation  for  more  than  200  men.  Some  single  rooms 
as  described  above  (Citadel),  others  large,  well-ventilated,  high-ceilinged 
dormitories,  the  beds  being  double-tier  iron-spring  bunks.  Each  separate 
room  having  a  floor  space  of  40  square  feet  and  air  space  of  400  cubic  feet, 
the  dormitory  having  45  square  feet  of  space  per  individual  and  450  cubic 
feet  air  space  per  capita.  Premises  in  clean  condition.  Shower  baths  in 
cellar.  Laundry  tubs  for  men  to  wash  clothes  and  drying  room  for  their 
use.  Usual  standards  of  simplicity  and  adequate  cleanliness  that  one  finds 
in  Salvation  Army  quarters.  Occasionally  inspected  by  the  Health  Division, 
Charge  of  50  cents  per  room  and  35  cents  per  bed  in  dormintory. 

Palisades,   2146   Ontario  Street 

One  flight  up  to  pool  room,  lunch  counter,  general  lounging  room  and 
a  few  unlighted,  unventilated  cabins  with  semi-partitions,  the  ceiling  of  each 
being  formed  by  wire  gratings  on  which  newspapers,  rags  and  rubbish  have 
accumulated  almost  to  the  exclusion  of  air.  Two  floors  above  this  used 
for  lodging  purposes,  the  rooms  being  wholly  inadequate  as  to  light,  floor  space 
and  cubic  air  space.  The  washrooms  are  filthy,  the  bedding  old,  the  single 
sheet  and  so-called  pillow  case  being  grey  and  brown  with  dirt  and  discharges, 
the  mattresses  stained  and  torn,  the  coverlets  filthy  with  stains  of  vermin 
and  men.  The  per  capita  floor  space  allowed  was  35  square  feet  and  the 
air  space  280  cubic  feet.  There  was  no  light  in  the  separate  rooms  and  many 
of  the  rooms  were  pitch  dark  in  the  middle  of  a  bright  afternoon.  Kerosene 
lamps  were  had  by  some  of  the  men  in  the  rooms  and  some  of  the  rooms 
were  furnished  by  the  men  with  all  kinds  of  personal  belongings.  Men  were 
found  who  had  lived  in  these  rooms  for  months  at  a  time  at  $2.00  a  week. 
No  proprietor  or  clerk  on  the  premises  and  did  not  learn  whether  place  was 
licensed.  Neither  as  to  cleanliness,  air  space,  bedding  or  lighting  does  this 
building  comply  with  what  are  recognized  standards  for  even  the  cheapest 
lodging  houses  in  New  York  City. 

131    West  Prospect  Avenue 

Two-story  building.  First  floor  occupied  by  lunch  counter,  kitchen, 
lounge  room  and  card  room.  Crowded  with  Negroes,  Italians,  Poles,  etc. 
Eleven  sleeping  rooms  on  the  second  floor  in  rear;  the  proprietor    occupying 


Environment  and  Sanitation  55 


the  front.  These  rooms  are  furnished  with  beds  with  filthy  mattresses  and 
bedding.  Some  beds  double.  Some  rooms  with  two  cots.  Floor  space 
35  square  feet  per  capita.  The  rooms  with  the  exception  of  one  had  each 
an  outside  window.  This  place  has  no  license  because  the  inspector  from 
Columbus  said  that  with  so  small  a  number  of  rooms  it  was  unnecessary  to 
have  a  license. 

The  serving  of  food  in  the  restaurant  on  the  ground  floor  was  under  the 
foulest  imaginable  conditions.  Butter  was  picked  out  of  the  bowls  with 
dirty  hands.  Food  for  serving  was  standing  around  on  the  floor  in  the 
kitchen  and  behind  the  lunch  counter.  No  order,  cleanliness  or  provision 
for  decent  washing  of  dishes  or  hands.  The  apparently  total  neglect  of  all 
provision  for  decent  food  preparation  is  one  of  the  striking  features  observed 
on  visiting  a  large  number  of  eating  houses  and  lunch  counters  feeding  the 
transient  or  lodging-house  public  of  the  city. 

Lodging  House  maintained  at  the  New  York  Central  Freight  Depot 

132  men  were  in  one  cellar  space  entirely  below  ground  excepting  for  a 
space  of  six  inches  which  permits  of  partially  open  windows,  looking  out  at 
street  level  on  one  side  and  on  car  tracks  upon  the  other.  Cubic  space 
240  feet  per  capita.  Double-deck  bunks,  some  for  two  people  each;  bunks 
two  and  three  tiers  deep,  so  close  together  that  a  sick  man  must  be  reached 
over  the  foot  of  the  bed  for  examination  and  treatment.  Only  artificial  light 
possible.  Provision  for  toilets  and  wash  basins  excellent  and.  adequate. 
Another  room  for  72  men,  290  cubic  feet  per  capita,  with  the  same  double- 
deck  bunks  in  two  and  three  rows,  a  place  with  insufficient  ventilation  and 
light  to  permit  of  the  requirements  of  housing  and  unfit  for  human  habitation 
according  to  the  Building  Code  of  almost  any  of  the  cities  of  the  United 
States.  Reported  by  district  physician  to  be  a  constant  source  for  medical 
care  at  the  expense  of  the  city  through  the  winter,  when  the  condition,  due 
to  lack  of  ventilation,  was  beyond  belief.  There  was  no  medical  care  pro- 
vided by  the  company  for  this  group  of  not  less  than  200  and  frequently  250 
to  300  men.  One  exhaust  fan  opening  out  at  the  level  of  the  railroad  tracks 
offers  opportunity  for  change  of  air,  but  in  winter  the  windows  were  kept 
shut  constantly,  and  the  intake  of  air  must  come  in  any  event  from  the 
street  level  with  all  the  dust  of  the  large  truck  spaces  of  the  freight  yard. 


RECOMMENDA  TIONS 

It  is  recommended  that: 

The  activities  of  the  Chamber  of  Commerce  in  the  interest  of  suitable  housing  in 
single  or  two-family  buildings  be  continued,  and  that  there  be  added  to  the  present  impor- 
tant financial  undertaking  to  facilitate  home  building  for  wage  earners,  educational  prop- 
aganda among  householders  as  to  proper  and  legal  standards  of  construction,  equipment 
and  occupancy  of  living  premises,  so  that  those  owning  or  renting  homes  may  know  their 
own  duties  and  privileges  or  rights,  as  well  as  the  degree  and  kind  of  protection  they  are 
entitled  to  at  the  hands  of  the  city  government  for  the  protection  of  their  health. 


56  Hospital  and  Health  Survey 


The  undertaking  of  the  City  Plan  Commission  to  establish  a  plan  by  zones  for  the 
construction  and  use  of  buildings  be  vigorously  and  continuously  supported  by  all  civic 
agencies  such  as  the  Chamber  of  Commerce,  the  Welfare  Federation,  the  Consumers' 
League,  etc.,  until  the  city  government  has  enacted  into  law  adequate  restrictions  and 
provisions  for  the  future. 

The  existing  laws  affecting  the  occupancy  of  premises,  whether  tenements,  lodging 
houses  or  single-family  houses  now  used  for  multiple  family  use,  be  enforced  consistently, 
impartially  and  vigorously,  to  the  end  that  the  existing  disgraceful  conditions  in  and 
about  living  quarters  of  the  poor  in  Cleveland  be  abated. 

The  proposed  Sanitary  Code  be  enacted  into  law  at  the  earliest  possible  date  to  give 
the  Division  of  Health  the  necessary  authority  to  take  action  in  lodging  houses  and  to 
enforce  the  abatement  of  nuisances. 

The  authority  to  license,  inspect,  control  and  close  lodging  houses  in  Cleveland  be 
vested  in  the  office  of  the  Commissioner  of  Health  or  the  Director  of  Welfare  of  Cleveland,' 
if  necessary,  as  the  agent  of  the  State  Fire  Marshal  at  Columbus. 


Environment  and  Sanitation  .  57 

Water  Supply 

WITHOUT  repeating  the  historical  record  of  events,  it  may  be  briefly 
stated  here  that  Cleveland  has  been  through  the  same  phases  of  in- 
difference, alarm,  actual  fear,  confidence  and  now  pride  with  regard 
to  its  municipal  water  supply  which  has  been  characteristic  of  many  lake 
cities.  Cleveland's  water  supply  is  now  protected  by  the  location  of  intake 
in  the  lake,  by  filtration  and  by  chlorination,  so  that  the  citizens  receive, 
except  in  a  small  part  of  the  city  for  which  filtered  water  cannot  be  obtained 
until  construction  already  planned  for  is  completed,  a  safe,  potable  water, 
attractive  in  appearance  and  suitable  for  all  domestic  and  commercial  uses. 
There  is  no  reason  to  believe  that  communicable  disease  of  any  kind  is  now 
distributed  by  the  public  water  supply.  No  one  in  Cleveland  needs  to  buy 
bottled  waters,  except  to  satisfy  some  whim  of  taste  or  appearance. 

The  source  of  supply  is  obviously  adequate  through  the  two  intakes 
about  four  and  one-half  miles  from  the  shore  in  Lake  Erie.  One  crib  is  of 
the  exposed,  the  other  of  the  submerged  type.  Tunnels  connect  these 
cribs  with  the  pumping  stations  at  the  foot  of  East  49th  Street  and  on  Divi- 
sion Avenue,  at  the  foot  of  West  45th  Street,  90  per  cent  of  the  pumpage  being- 
done  at  present  at  the  latter  station,  where  the  filtration  plant  is  in  operation, 
with  a.  daily  capacity  of  about  150,000,000  gallons.  Steel  pipe  lines  carry  the 
raw  water  to  the  chemical  house  whence  it  passes  to  the  mixing  chamber. 
Sulphate  of  iron  (110-140  lbs.  per  million  gallons)  and  lime  (85-100  lbs.  per 
million  gallons)  are  supplied  automatically  in  solution  to  the  raw  water  in  the 
steel  pipe  lines,  according  to  the  rate  of  flow  and  the  condition  of  the  water. 
Coagulation  of  removable  matter  is  facilitated  in  the  mixing  chambers,  and 
the  settling  out  takes  place  between  the  mixing  chambers  and  the  filter  build- 
ings. 

The  filters  are  cleaned  every  10  to  40  hours,  according  to  the  condition 
of  the  water,  by  reversing  the  flow  through  the  beds.  The  filtered  water  is 
stored  in  a  20  million  gallon  reservoir,  whence  it  is  distributed  by  pumps 
through  the  city  pipe  system.  The  lake  water  carries  but  little  suspended 
matter  for  most  of  the  year  and  purification  is  needed  chiefly  to  reduce  the 
bacterial  content  of  the  water.  There  is  a  reservoir  for  surplus  water.  At  the 
matter  for  most  of  the  year  and  purification  is  needed  chiefly  to  reduce  bac- 
terial content  of  the  water.  There  is  a  reservoir  for  surplus  water.  At  the 
pumping  station  on  the  East  Side  the  process  is  identical  except  that  filtra- 
tion is  not  yet  provided,  though  planned  for.  Most  of  the  water  distributed 
to  the  East  Side  of  the  city,  as  well  as  all  that  for  the  West  Side,  comes  from 
the  West  Side  station  and  has  been  filtered  as  well  as  chlorinated. 

Complaints  of  unpleasant  taste  in  the  water  have  been  found  justified  at 
times,  not  because  of  excessive  or  irregular  use  of  lime  or  chemicals  applied 
at  the  pumping  stations,  but  because  of  pollution  of  the  water  in  the  vicinity 
of  the  intake  cribs  by  melting  ice  or  obstructed  flow  from  the  Cuyahoga  River, 
which  occurs  under  certain  conditions  of  wind  and  temperature,  and  always 
in  the  winter  season. 

The  water  is  tested  daily  both  by  the  laboratory  of  the  Water  Division 
of  the  Department  of  Public  Utilities  and  by  the  laboratory  of  the  Division 


.58  Hospital  and  Health  Survey 


of  Health,  sample;  being  taken  regularly  from  points  at  the  pumping  station 
before  and  aftei  filtration  and  chlorination,  and  at  various  police  stations 
and  other  suitable  points  in  the  city.  Tables  giving  the  results  of  chemical 
and  bacteriological  tests  made  at  the  two  laboratories  show  consistent  find- 
ings in  the  effect  of  chlorine  treatment  (.271-. 454  parts  per  million)  in  dimin- 
ishing the  occurrence  of  the  presumptive  test  for  fermentative  organisms 
(according  to  standards  proposed  by  the  American  Public  Health  Associa- 
tion), and  also  give  evidence  of  the  uniformity  in  tests  made  of  water  collected 
at  widely  distributed  points  on  both  sides  of  the  city. 

One  of  the  very  considerable  economies  to  the  householder  is  the  degree 
of  softness  of  the  public  water  supply  provided  by  the  method  of  treatment. 
The  saving  in  soap  alone  to  the  people  of  Cleveland  is  worth  many  times  the 
cost  of  chemical  treatment  of  the  water.  When  the  plans  already  decided 
upon  are  completed  there  will  be  pumped  and  filtered  water  in  abundance 
for  one  and  a  half  to  two  million  people. 

The  city  sells  water  to  Lakewood,  East  Cleveland,  Cleveland  Heights, 
Shaker  Heights  and  West  Park.  The  city  is  metered  and  wasted  water  is 
paid  for.  Water  is  now  furnished  for  a  population  of  about  one  million 
people  who  reside  in  an  area  of  about  110  square  miles.  The  average  rate 
of  consumption  is  estimated  at  from  130  to  135  million  gallons  daily  and  the 
maximum  rate  of  consumption  at  200  million  gallons  daily.  Nearly  the 
entire  pumpage  is  accounted  for,  a  fact  which  would  indicate  that  the  dis- 
tribution system  is  in  good  condition.  Improvements  in  the  water  supply 
and  distribution  have  always  been  more  than  met  by  the  water  rates,  which 
are  not  excessive. 

The  growth  of  Cleveland  and  its  vicinity  is  an  assured  fact,  consequently, 
at  intervals  water  facilities  must  be  increased  to  meet  the  growing  demand. 
With  sewage  treatment  provided  only  to  the  extent  of  safeguarding  bathing 
beach  waters  and  minimizing  the  foul  condition  of  the  Cuyahoga  River, 
the  contamination  of  the  lake  shore  waters  will  increase  with  the  growth  of 
the  city.  Therefore,  in  completing  present  plans  and  in  making  future  ones 
the  filtration  of  the  city  water  should  be  considered  of  paramount  importance. 

With  two  filtration  plants,  each  with  a  capacity  of  150  million  gallons 
daily,  it  seems  that  pure  and  wholesome  Avater  will  be  furnished  this  com- 
munity for  a  number  of  years.  However,  recently  a  committee  of  Engin- 
eers, Messrs.  Hoffman,  Herron  &  Frazier,  studied  the  future  requirements 
of  the  Water  Department  and  concluded  that  by  the  year  1940  two  addi- 
tional filtration  plants,  one  east  and  one  west  of  the  Cuyohoga  River,  would 
probably  be  necessary. 

There  is  no  reason  to  believe  that  the  water  supply  is  responsible  for  any 
of  the  typhoid  fever,  dysentery  or  other  diarrheal  diseases  reported  and 
analyzed, since  chlorination  of  the  entire  supply  was  established.  The  very 
low  typhoid  rate  of  Cleveland  during  the  year  1919  is  an  excellent  proof  of 
the  safely  of  the  public  water  supply. 

With  regard  to  private  unauthorized  and  individual  well  supplies  of 
water  used  in  the  outlying  districts  of  the  city  and  its  suburbs  not  yet  reached 


Environment  and  Sanitation  59 

by  the  public  supply,  the  situation  is  unsatisfactory.  There  is  no  map  or 
census  of  these  supplies,  .and  there  is  no  system  of  inspection,  or  permit 
system  controlling  the  use  of  other  than  public  water  supplies  by  the  Division 
of  Health.  Some  of  the  cases  of  enteric  infection,  for  which  the  source  has 
not  been  traced  in  the  great  majority  of  cases  may  well  be  due  to  individual 
^ell  supplies  exposed  to  surface  or  other  contamination  regularly  or  occa- 
sionally. No  one  should  be  permitted  to  use  water  supply  other  than  the 
public  source  unless  the  quality  of  water  and  the  sanitary  safety  of  its  en- 
vironment and  drainage  area  are  known  to  the  Division  of  Health  and  a 
permit  or  license  for  the  use  of  such  water  is  issued  and  only  on  the  basis  of 
bacteriological  and  sanitary  control  at  frequent  intervals. 

It  is  recommended  that: 

The  plans  for  filtration  as  prepared  for  the  East  45th  Street  pumping  station  be 
carried  to  completion  and  that  the  present  chemical  and  bacteriological  standards  for 
quality  and  purity  of  the  water  supply  be  maintained. 

The  Division  of  Health  make  a  careful  survey  to  locate  all  sources  of  water  supply  in 
Cleveland  other  than  the  public  supply  and  permit  the  use  of  only  such  as  are  found  by 
chemical,  bacteriological  and  sanitary  standards  to  be  continuously  fit  for  human  use. 


60  Hospital  and  Health  Survey 


Sewage  Disposal 

WHERE,  as  in  Cleveland,  the  drinking  water  is  taken  from  the  same 
natural  source  into  which  surface  drainage  and  household  and  indus- 
trial sewage  naturally  empties  by  gravity,  the  collection,  treatment  and 
disposal  of  sewage  becomes  of  almost  as  much  importance  as  the  purification 
of  the  water  supply.  Moreover,  the  use  of  the  lake  shore  and  beaches  in 
and  near  the  city  for  recreation  purposes,  boating,  paddling,  bathing,  etc., 
is  an  added  reason  to  exclude  or  reduce  to  a  safe  dilution  the  sewage  effluent. 
Cleveland's  present  sewer  system  for  collection,  the  facilities  for  treatment 
and  the  location  of  discharge  outlets  in  deep  water  far  from  shore,  as  con- 
structed or  planned  for,  and  under  contract,  represent  the  best  engineering 
opinion  and  the  result  of  important  practical  experiments  with  a  great  variety 
of  treatment  and  disposal  methods. 

Until  the  city  has  so  treated  its  own  sewage  from  the  areas  which  will 
contribute  to  the  discharge  into  the  upper  part  of  the  Cuyahoga  River  as  to 
escape  criticism  and  avoid  nuisance,  the  industrial  plants  along  the  banks  of 
the  river  cannot  be  required  to  abate  the  nuisances  they  are  so  obviously  and 
so  offensively  guilty  of  at  present.  The  opportunities  for  the  great  indus- 
tries of  Cleveland  to  contribute  to  the  cleanliness  of  air  and  water  are  so  am- 
ple that  one  would  think  they  might  tempt  the  imagination  of  some  engineer 
among  them. 

The  bird  that  fouls  its  own  nest  is  a  true  "white-wing"  in  comparison 
with  the  collection  of  industrial  plants  upon  the  flats  of  the  Cuyahoga  River. 

The  Cleveland  program  includes  the  controlling  of  the  purity  of  the  drink- 
ing water  by  treatment  during  the  immediate  future  in  two  large  filtration 
plants  and  the  safeguarding  of  the  bathing  beach  waters  from  sewage  pollu- 
tion by  treating  the  sewage  in  three  large  treatment  plants.  Treating  the 
sewage  is  the  first  major  step  in  eliminating  the  foul  and  objectionable  con- 
ditions existing  in  the  water  of  Cuyahoga  River,  while  another  benefit  to  be 
derived  pertains  to  the  prevention  of  the  overtaxing  or  overloading  the  reason- 
able performance  of  the  water  purification  plants.  Another  important  bene- 
fit to  be  expected,  although  chiefly  sentimental,  is  the  meeting  of  the  opposi- 
tion of  the  public  to  the  use  of  a  source  of  water  for  drinking  purposes  in 
which  there  exists  even  a  suspicion  of  sewage  pollution. 

The  policy  which  has  been  adopted  in  Cleveland  is  similar  to  that  in 
general  use  in  this  country  and  abroad,  namely:  controlling  the  purity  of 
the  water  by  filtration  and  treating  the  sewage  only  to  a  partial  extent. 
Lake  Erie  waters  near  centers  of  population  are  becoming,  year  by  year, 
less  reliable  as  a  source  for  a  water  supply  without  treatment.  Filtration 
in  conjunction  with  sterilizing  agents  will  alone  make  the  public  water  supply 
of  this  community  satisfactory  under  existing  conditions,  and  it  is  with  this 

*  The  Survey  is  indebted  to  various  officers  in  the  employ  of  the  city  for  most  of  the  information 
regarding  water  supply  and  sewage  in  Cleveland,  and  in  particular  we  wish  to  acknowledge  the  impor- 
tant statements  of  fact  obtained  from— 

Mr.  George  B.  Gascoigne,  Sanitary  Engineer,  Division  of  Engineering  of  the  Department  of  Public 
Service,  and 

Dr.  Roger  Perkins,  Chief  of  the  Eureau  of  Laboratories  of  the  Division  of  Health  and  Prv,  «ssor  of 
Bacteriology  and  Hygiene  at  the  Western  Reserve  University  Medical  School. 


Environment  and  Sanitation  61 


viewpoint  in  mind  that  the  problem  of  sewage  treatment  has  been  dealt 
with.  With  efficient  operation  of  both  water  and  sewage  plants  two  bar- 
riers against  the  contamination  of  the  water  supply  will  be  established. 

The  program  adopted  is  representative  of  the  progressive  spirit  in  the 
community  and  it  should  be  consummated  in  its  entirety.  It  demands  the 
attention  of  the  public  until  all  of  the  contemplated  structures  are  in  use, 
and  it  should  be  stated  that  the  efficient  operation  of  the  sewerage  and  sewage 
treatment  works  is  just  as  important  as  the  installation  of  the  works. 


Sewerage 

The  city  of  Cleveland  is  sewered  upon  the  combined  plan,  i.  e.,  one  set 
of  sewers  cares  for  the  storm  water  and  sewage.  Lake  Erie  is  the  ultimate 
dumping  ground  for  all  the  sewage  flowing  through  the  city  system,  which 
may  be  described  as  a  series  of  main  sewers  having  outlets  for  excess  storm 
water  emptying  either  directly  into  the  lake  or  into  streams  tributary  thereto. 
The  sanitary  sewage,  together  with  the  first  flush  of  storm  water,  is  to  be 
collected  from  the  above-mentioned  main  sewers  by  means  of  a  system  of 
intercepting  sewers  which  discharge  at  the  selected  points  for  treatment. 
These  treatment  sites  are  three  in  number,  two  on  the  lake  front  and  one 
on  the  Cuyahoga  River. 

The  first  sewers  were  built  in  Cleveland  about  70  years  ago,  and  today 
we  find  very  few  of  these  in  use.  The  rapid  growth  of  the  city  has  made 
necessary  the  construction  of  many  miles  of  sewers.  However,  the  increase 
in  sewer  mileage  apparently  has  not  kept  pace  with  the  increase  in  street 
mileage.  There  are  many  factors  governing  this  condition,  principal  among 
which  is  the  inadequacy  of  financing. 

The  demand  for  sewers  includes  projects  for  main  sewers,  some  of  which 
are  partially  completed,  sewers  for  recently  annexed  portions  of  the  city 
and  sewers  for  undeveloped  portions.  Furthermore,  there  are  many  sewers 
needing  rebuilding  in  advance  of  paving,  and  there  are  a  number  of  streams 
which  must  be  maintained  as  storm  water  channels  which  should  be  con- 
verted into  storm  sewers.  The  city  now  has  about  17  miles  of  streets  and  only 
about  15  miles  of  sewers  to  the  square  mile.  In  order  to  make  the  sewer 
mileage  equal  to  the  street  mileage,  an  additional  sewer  length  of  about  106 
miles  would  be  required. 

It  is  found  that  the  city  has  been  expending  for  sewer  purposes  about 
$1,000,000  each  year.  Mr.  Robert  Hoffman,  Commissioner  of  Engineering 
and  Construction,  estimates  that  the  city  will  need  to  expend  about  $1,000,000 
each  year  for  the  next  10  to  15  years  before  it  can  provide  sewerage  facilities 
commensurate  with  the  present  and  future  demand.  Available  data  tend  to 
show  that  at  the  present  time  the  city  is  about  88  per  cent  sewered,  a  ratio 
which  compares  favorably  with  that  found  in  most  of  the  larger  cities. 

Under  existing  laws  the  city  as  a  whole  must  pay  the  cost  of  sewers 
located  within  street  intersections  and  at  least  two  per  cent  of  the  remaining 
cost.  Abutting  property  can  not  be  assessed  for  more  than  would  be 
required  to  pay  the  cost  of  a  local  sewer,  so  that  the  excess  cost  of  any  branch 


62  Hospital  and  Health  Survey 

or  main  sewer  over  or  above  what  a  local  sewer  would  cost  must  be  borne  by 
the  city  as  a  whole.  This  portion  of  the  cost  is  substantial  and  accounts  in 
large  measure  for  the  amount  the  city  must  pay.  The  city's  portion  of  the 
cost  is  usually  financed  through  the  sale  of  bonds  issued  for  such  purposes, 
but  the  amount  of  bonds  which  can  be  issued  is  limited  in  a  number  of  ways. 

Sewage  Treatment 

There  is  evidence  that  the  bathing  beach  waters  along  the  lake  front  are 
polluted  by  sewage  now  discharged  at  the  main  sewer  outlets  and  at  times 
by  the  storm-water  emergency  outlets  discharging  diluted  sewage.  Proof 
of  the  origin  and  spread  of  communicable  diseases  by  sewage-polluted  water 
used  for  bathing  purposes,  is  difficult  to  obtain,  but  sufficient  instances  of 
typhoid  fever,  non-specific  intestinal  infections  and  of  infectious  conjunc- 
tivitis have  been  observed  in  New  York  City  and*  elsewhere  as  the  result  of 
unrestricted  use  of  bathing  beaches  near  sewer  outfalls,  justify  our  pro- 
tecting bathing  waters  against  pollution  or  forbidding  bathing  when  the 
pollution  can  be  demonstrated.  Bacteriological  proof  of  the  degree  of 
sewage  pollution  is  usually  unnecessary,  for  sight  and  smell  suffice  to  give 
warning  and  evidence.  The  locations  for  the  sewage  plants,  together  with 
the  degree  of  treatment  necessary  and  the  type  of  sewage  plants  best  suited 
to  local  conditions,  were  determined  from  tests  on  the  sewage  discharged 
at  the  East  140th  Street  and  the  West  58th  Street  outlets. 

The  city,  as  may  be  seen  from  the  accompanying  map,  has  been  divided 
into  four  main  sewerage  districts:  the  Westerly,  Easterly,  Southerly  and 
Low  Level.  Each  district,  with  the  exception  of  the  Low  Level,  has  a  main 
intercepting  sewer  to  deliver  sewage  to  the  treatment  site,  and  the  population 
served  in  each  district  amounts  to,  approximately,  27  per  cent,  50  per  cent, 
22  per  cent  and  1  per  cent  of  the  total  population  of  the  city,  respectively. 
The  sewage  of  the  Westerly  and  Easterly  districts  will  be  treated  at  two 
lake-front  plants,  while  the  sewage  from  the  remainder  of  the  city  will  be 
treated  at  a  plant  located  on  the  Cuyahoga  River,  about  seven  miles  from  its 
mouth.  Since  lake  water  is  not  available  at  this  site,  it  appears  that  ulti- 
mately structures  which  provide  a  higher  degree  of  treatment  than  at  the 
lake-front  sites  will  be  necessary  at  this  site.  Since  contemplated  river  and 
harbor  improvements  along  the  Cuyahoga  River  involve  an  extensive  plan 
for  straightening  the  river  channel,  the  problem  of  sewage  disposal  for  the 
Low  Level  district  which  bounds  the  river  is  rendered  especially  uncertain  at 
this  time. 

The  primary  results  to  be  accomplished  by  sewage  treatment  works 
may   be  listed  as  follows: 

Preventing  the  pollution  of  bathing  beach  waters  along  the  lake  front. 

Kliininating  the  foul  condition  of  the  Cuyahoga  River. 

At  the  Westerly  site  there  has  been  constructed  a  submerged  outfall,  and 
a  complete  sew  tge  treatment  plant  is  now  under  construction.  It  is  expected 
that  this  will  be  completed  and  in  continuous  operation  by  the  bathing 
sf>i-;<m  of  1921.    At  the  Easterly  site,  shore  protection  works,  outfall  pipes 


Environment  and  Sanitation 


63 


J  L. 


64  Hospital  and  Health  Survey 


and  a  building  for  the  housing  of  disinfection  equipment  have  been  con- 
structed. There  is  now  under  construction  at  this  site  a  sewage  plant  for 
partial  treatment  which  is  expected  to  be  completed  and  ready  for  operation 
by  the  bathing  season  of  1921.  At  the  Southerly  site  the  river  has  been 
straightened  and  a  portion  of  the  excavation  has  been  made  for  the  sewage 
plant.  •, 

When  the  two  lake  front  plants  are  completed  they  will  provide  for 
removing  the  inorganic  matter  of  sewage  by  sedimentation  in  grit  chambers, 
and  the  removal  of  settleable  organic  matter  by  settling  in  two-story  tanks. 
During  the  bathing  season  the  tank-treated  sewage  is  to  be  chlorinated  and 
dispersed  in  wide  areas  about  one-half  mile  off  shore  by  means  of  submerged 
outfalls.  Should  it  be  possible  to  proceed  at  this  time  with  a  plant  at.  the 
up-river  or  Southerly  site  it  would  probably  provide,  in  addition  to  the 
tank  treatment  mentioned  above,  oxidation  of  the  sewage  in  sprinkling 
filters.  However,  the  final  selection  of  the  type  of  plant  to  be  constructed 
at  this  site  will  be  deferred  until  funds  are  available.  Thus  it  is  seen  that 
definite  and  substantial  progress  is  being  made  to  prevent  the  sewage  pollu- 
tion of  the  bathing  beach  waters. 

Financial  Aspect  of  Problem 

The  Water  Department  of  the  city  of  Cleveland  is  able  to  charge  rates 
which  are  consistent  with  the  cost  of  supplying  a  purified  water  to  all  parts 
of  the  city.  This  applies  not  only  to  providing  funds  for  operating  the 
water  works  in  an  efficient  and  economical  manner,  but  also  for  retiring  bonds 
incident  to  new  construction  work.  The  cost  of  constructing  and  operating 
filtration  plants  necessarily  increases  the  cost  to  the  city  of  supplying  water. 
In  addition  to  this  increase  the  cost  of  labor  and  supplies  have  also  advanced. 
To  take  care  of  the  additional  cost,  the  water  rates  were  recently  increased 
.50  per  cent,  so  that  domestic  consumers  within  the  city  are  now  charged  60 
cents  per  thousand  cubic  feet.  This  charge  is  reasonable  and  is  in  line  with 
that  found  in  other  large  cities  of  this  country. 

The  problem  of  additional  funds  for  sewage  and  sewage  disposal  works 
may  be  classified  under  two  headings:  namely,  funds  for  construction  work 
and  funds  for  the  operation  and  maintenance  of  the  various  sewage  plants. 

Funds  for  constructing  the  sewage  disposal  plants  were  provided  by  bond 
issues  and  their  authorization  was  approved  by  a  vote  of  the  people.  Since 
such  bonds  were  provided  in  compliance  with  orders  from  the  State  Depart- 
ment of  Health  they  were  issued  in  addition  to  the  usual  limits  governing 
the  bonded  indebtedness  of  the  city.  When  an  increase  in  the  tax  levy 
beyond  the  prescribed  limits  sufficient  to  provide  for  the  sinking  fund  and 
interest  charges  upon  sewage  disposal  bonds  becomes  necessary,  it  requires 
a  vote  of  the  people. 

There  had  been  expended  by  January  1,  1920,  upon  the  sewage  disposal 
project  about  $2,6.50,000  and  there  was  available  at  that  time  $1,330,000 
additional.  The  cost  of  completing  the  two  lake  front  plants  is  estimated 
at  $1,260,000,  which  means  that  available  funds  will  be  practically  depleted 
when  the  two  lake  front  plants  are  in  operation. 


Environment  and  Sanitation  65 


In  order  to  complete  the  Southerly  Interceptor  Sewer,  with  connections, 
and  the  Southerly  treatments  works,  additional  funds  to  the  extent  of  prac- 
tically $2,000,000  must  be  provided. 

The  statutes  of  the  state  of  Ohio  do  not  permit  levying  taxes  outside  the 
usual  limits,  for  the  operation  and  maintenance  of  sewage  disposal  improve- 
ments. The  time  is  rapidly  approaching  when  the  question  of  increasing 
the  present  tax  levy  to  provide  operation  funds  for  this  purpose  must  receive 
consideration  and  be  settled. 

The  problem  of  providing  funds  for  any  sewers  is  difficult,  yet  it  should 
be  appreciated  that  the  city  must  keep  pace  with  the  demand.  This  demand 
is  great  enough  to  require,  during  the  next  15  years,  an  annual  expenditure 
by  the  city  of  approximately  $1,000,000.  The  real  problem  confronting  the 
city  as  regards  sewerage  facilities  pertains  to  the  method  which  shall  be 
adopted  in  financing  such  improvements. 

The  result  of  failure  to  supply  sewers  and  keep  pace  with  the  settle- 
ments and  building  projects  in  the  outlying  parts  of  the  city  can  be  seen, 
perhaps,  in  its  typical  expression  in  the  Collinwood  region,  where  the  kitchen 
waste  and  overflow  from  numerous  shallow  cesspools  and  privy  vaults  is 
carried  in  open  gutters  behind  rows  of  houses  across  sidewalks  and  through 
deviou  >  channels,  until  the  foul-smelling  stream  seeps  away  if  the  ground 
is  dry  or  reaches  Nottingham  Creek  if  the  clay  soil  cannot  absorb  it.  Noth- 
ing can  so  successfully  discourage  attempts  by  the  householder  and  the 
sanitary  police  to  maintain  decent  surroundings  for  the  little  children  of 
such  regions  as  the  absence  of  sewers  while  the  public  water  supply  is  every- 
where available.  A  sewer  is  about  as  essential  as  a  trolley  line  to  develop 
suburbs  and  distribute  families  away  from  the  packed  tenements  of  the  city. 

One  particularly  foul  spot  was  found  adjacent  to  the  city  filtration  plant : 
namely,  at  Bentley  Court,  where  a  small  area  inhabited  fairly  densely  by 
people  of  small  means  is  entirely  unsewered.  Here  the  slops  and  privy 
vaults  overflow  and  leakage  from  a  row  of  houses  has  made  a  small  swamp 
alongside  of  what  serves  as  a  roadway,  where  domestic  animals  and  children 
find  entertainment,  and  where  the  passerby  holds  his  nose  for  the  stench. 
It  takes  a  high  grade  of  intelligence,  constant  industry  and  real  discipline 
to  live  at  close  quarters  and  not  create  nuisances,  where  sewers  are  lacking 
and  water  supply  is  provided. 

Summary 

The  problem  of  safeguarding  the  health  of  any  community  by  supplying 
a  pure  water  and  by  removing  the  sewage  pollution  from  bathing  beach 
waters  warrants  considerable  attention  by  the  public.  This  is  especially 
true  in  a  large  and  growing  community.  During  the  past  few  years  these 
problems  have  been  studied  actively  and  conscientiously  in  Cleveland,  with 
the  result  that  comprehensive  plans  for  providing  suitable  water  supply, 


66  Hospital  and  Health  Survey 

sewerage  and  sewage  disposal  facilities  have  been  adopted  and  are  being 
carried  out  with  substantial  progress  to  date.*  The  situation  may  be  sum- 
marized as  follows : 

1.  While  the  domestic  supply  of  water  in  the  City  of  Cleveland  and 
vicinity  can  not  be  considered  entirely  satisfactory,  physically  and  hygieni- 
cally,  without  treatment,  excellent  progress  has  been  made  to  furnish  a  pure 
water  supply  by  means  of  intakes  suitably  located  off-shore  and  by  adequate 
filtration  and  chlorination. 

2.  Progress  is  being  made  in  providing  sewerage  facilities.  However,  the 
demand  for  sewers  is  extraordinary  at  this  time,  and  this  demand,  because 
of  the  rapid  expansion  of  the  city,  will  continue  during  the  immediate  future. 
In  order  to  meet  this  demand  expenditures  of  large  sums  must  be  made 
for  sewers. 

3.  The  bathing  beach  waters  along  the  lake  front  are  subjected  to  con- 
tinuous pollution  from  sewage  discharged  at  the  outfalls,  and  to  occasional 
pollution  from  diluted  sewage  discharged  from  storm  water  overflow  outlets. 

The  foul  condition  of  the  Cuyahoga  River  has  long  been  a  source  of 
complaint.  While  correcting  this  condition  may  be  considered  partly  a 
sentimental  or  comfort  problem,  sight  should  not  be  lost  of  the  fact  that 
this  stream  with  its  polluting  materials  is  a  direct  menace  to  the  water  supply. 

4.  An  investment  of  approximately  $4,000,000  for  sewage  treatment 
devices  will  be  rendered  practically  worthless  unless  funds  are  provided  to 
operate  and  maintain  such  works  in  an  efficient  manner.  The  question  of 
providing  such  funds  should  be  given  serious  consideration  in  the  imme- 
diate future. 


RECOMMENDA  TJONS 

It  is  recommended  that: 

The  City  persevere  with  its  present  excellent  plan  for  sewage  collection  treatment 
and  disposal. 

For  sewer  extensions  the  sum  of  $1,000,000  be  provided  annually  for  the  next  fifteen 
years,  to  permit  of  a  wise  and  consistent  development  of  the  present  plan  and  to  permit 
of  economies  in  construction. 

Cooperation  be  arranged  for  between  the  Park  Department,  the  Public  Service  De- 
partment and  the  Division  of  Health  to  assure  protection  of  the  public  against  risk  of 
infection  from  bathing  at  the  public  beaches  in  or  near  the  city  when  there  has  been  direct 
or  emergency  overflow  contamination  near  the  beaches,  due  to  heavy  rainfall  in  summer. 

Funds  be  provided  to  operate  and  maintain  the  sewage  treatment  works  in  the  manner 
intended  at  the  time  of  construction. 

*  For  those  who  wish  to  test  th?  standards  Cleveland  has  set  for  itself  in  its  present  plans  for  proper 
collection  and  disposal  of  sewage,  an  excellent  summary  of  standards  methods  and  authoritative  reference 
to  the  best  present-day  American  practice  can  be  found  in  the  special  article  on  this  subject  by  Hommon, 
Hoskins,  Streeter,  Tarbett  and  Wagenhals  in  the  U.  S.  Public  Health  Report  (January  16,  1920,<]Vol. 
35,  No.  3). 


Environment  and  Sanitation  <  67 

Street  Cleaning  and  the  Collection  and  Disposal  of 
Garbage  and  Refuse* 


o 


NE  of  the  most  important  municipal  problems  in  any  city  is  the  clean- 
ing of  streets  and  the  collection  and  disposal  of  garbage  and  other 
refuse. 


The  streets  may  be  efficiently  lighted,  well  paved  and  sewered,  but  from 
a  health  standpoint  how  much  more  essential  is  it  that  they  be  well  cleaned. 
Houses  are  constructed  with  all  modern  improvements,  including  provision 
for  ventilation,  with  sewer  connections,  etc.,  but  it  is  essential  for  the  occu- 
pants that  the  refuse  be  speedily  and  systematically  removed. 

We  hear  much  at  present  in  regard  to  parks  and  playgrounds  for  con- 
gested districts,  in  order  to  secure  for  the  people  who  live  and  work  in  these 
districts  better  hygienic  conditions.  Dr.  Peterson,  former  supervisor  of 
playgrounds  of  Cleveland,  estimated  that  the  supervised  playgrounds  in 
Cleveland  would  accommodate  20,000  children;  more  than  105,000,  he  said, 
will  have  to  play  in  the  streets.  In  discussing  parks  and  playgrounds  how 
little  we  hear  of  keeping  the  streets,  alleys,  yards,  courts  and  premises  in  a 
cleanly  condition,  to  secure  cleanliness  of  the  streets  for  the  people  who 
live  in  the  congested  sections,  to  protect  the  air  they  breathe,  the  houses 
they  live  in,  the  shops  they  work  in,  their  recreation  grounds.  Undoubtedly 
a  large  number  of  people  spend  their  lives  from  beginning  to  end  in  an  area, 
the  healthfulness  of  which  is  controlled  for  good  or  bad,  according  to  the 
method  adopted  for  cleanliness. 

The  work  in  connection  with  the  cleanliness  of  the  city,  consisting  in  the 
cleaning  of  streets  and  the  collection  and  disposal  of  refuse  and  garbage,  is 
under  the  direction  of  the  Director  of  Public  Service,  carried  on  by  branches 
of  the  Service  Department. 

Garbage  Collection  and  Disposal 

Prior  to  1897  there  was  no  systematic  method  for  collection  and  dis- 
posal of  garbage — the  garbage  being  collected  by  contractors,  who  made 
collections  from  all  portions  of  the  city  and  disposed  of  the  material  by 
taking  it  several  miles  out  into  the  lake  and  there  dumping  it.  The  method 
of j  disposal  was  not  satisfactory  on  account  of  the  excessive  cost  and  the 
littering  of  the  shores  with  floating  debris.  During  the  period  previous  to 
1897  a  portion  of  the  garbage  was  disposed  of  by  feeding  to  swine  on  farms 
inf  the  outlying  districts.  This  method  was  not  satisfactory  and  was 
finally  condemned  by  the  local  health  authorities. 

In  1897  a  contract  was  awarded  for  collection  and  disposal  for  a  period 
of  five  years,  the  contract  being  sublet  to  the  Newburgh  Reduction  Com- 
pany, with  a  plant  located  at  Willow,  on  the  Baltimore  &  Ohio  Railroad 


♦This  chapter  was  prepared  from  a  report  written  for  the  Survey  by  Mr.  I.  S.  Osborn,  an  engineer  of 
Cleveland  recently  engaged  by  the  city  government  to  make  an  exhaustive  study  of  the  problem  of  municipal 
collection  and  disposal  of  wastes.  The  Survey  is  privileged  to  present  this  statement  before  the  completion 
of  the  official  report. 


68  Hospital  and  Health  Survey 


just  south  of  Cleveland.  At  the  expiration  of  the  contract  it  was  not  x'e- 
newed  but  the  contractor  continued  to  perform  the  work  until  January  1, 
1905,  at  the  same  price  specified  in  the  contract,  $69,400  per  year. 

On  January  1,  1905,  the  entire  equipment  for  collection  and  disposal  of 
garbage  was  purchased  by  the  city  and  since  then  has  been  operated  by  the 
municipality.  . 

The  methods  of  collection  have  remained,  with  few  changes,  the  same  as 
when  the  work  was  taken  over  by  the  municipality.  The  original  horse- 
drawn  wagons  purchased  by  the  city  from  the  contractor  had  a  removable 
box,  which  was  removed  from  the  wagon  when  filled  and  shipped  to  the 
disposal  works,  with  an  empty  box  returned  and  placed  on  the  wagon  for 
use  in  the  next  collection. 

In  1907,  two  years  after  the  purchase  of  the  equipment  by  the  city, 
changes  and  improvements  were  made  bj?"  the  purchase  of  new  collection 
wagons  and  new  steel  garbage  cars,  as  made  necessary  by  improvements  in 
the  methods  of  handling  the  garbage  at  the  disposal  works. 

At  present  the  garbage  is  collected  from  the  various  sections  of  the  city 
in  steel-body  wagons,  in  which  it  is  delivered  to  the  central  receiving  stations 
where  it  is  dumped  into  steel  cars  and  shipped  to  the  reduction  works  at 
Willow. 

The  collection  and  disposal  of  garbage  are  supervised  by  two  superin- 
tendents, one  having  charge  of  collection  and  the  other  of  the  final  disposal. 
The  superintendent  of  collection  has  general  charge  of  the  equipment  and 
work  of  the  collection  department.  Under  him  are  employed  250  men,  en- 
gaged in  the  work  of  collection  and  maintenance  of  equipment  and  stables. 
The  superintendent  of  disposal  is  in  charge  of  the  reduction  works.  Under 
him  are  employed  approximately  100  men,  including  foremen,  mechanics, 
operators  and  laborers. 

Garbage  is  collected  from  all  sections  of  the  city,  which  has  an  area  of 
58.7  square  miles,  and  a  population  of  796,836.  The  total  area  of  the  city 
is  divided  into  101  collection  districts.  The  areas  of  the  districts  vary  from 
a  quarter  square  mile  to  one  square  mile  or  more,  depending  on  the  density 

of  population  and  quantity  of  material  to  be  collected.  It  is  the  intention 
in  estpbMshinjr  collection  districts  to  limit  the  size  so  as  to  permit  the  making 
of  regular  collections  on  schedule. 

The  collection  equipment  consists  of  the  collecting  wagons,  horses,  trucks 
and  trailers,  receiving  stations,  stables,  railroad  cars  and  miscellaneous  minor 
equipment.  The  receiving  station  and  stables  are  located  near  the  geo- 
graj  hical  center  of  the  city  on  Canal  Road.  The  site  comprises  approximately 
one-third  acre,  on  which  the  buildings  are  conveniently  located  as  to  railroad 
facilities  on  the  Baltimore  and  Ohio  Railroad,  for  shipment  of  garbage  to 
the  disposal  plant.  The  property  on  which  the  buildings  and  loading 
platform  are  located,  is  leased  for  a  short  term,  so  that  extensive  improve- 
ments  would    not   be   warranted.     The   location   is   objectionable  from   the 


Environment  and  Sanitation 


69 


A  winter's  collection  of  garbage  and  rubbish  under  the  kitchen  window. 


Even  the  cat  became  used  to  it.      This  garbage  has  waited  under  the  dining-room  window 
for  half  tin1  winter — for  the  collector 


Hospital  and  Health  Survey 


This  collection  of  old  food  was  the  winters  decoration  of  a  prominent  corner  in 

fl..„„l,.„,V  i.   nnrmpnipfl   (  hstricf. 


Cleveland's  congested  district 


Just  at  the  back  door.     Barrel  nearly  buried  by  pile  of  food  and  rubbish. 


Environment  and  Sanitation  71 

standpoint  of  approach,  due  to  the  fact  that  it  must  be  reached  by  steep 
grades  by  wagons  arriving  from  all  sections  of  the  city,  causing  considerable 
trouble,  especially  in  slippery  weather. 

Most  of  the  buildings  are  the  same  as  formerly  used  by  the  contractor. 
The  buildings  are  of  frame  construction  and  in  a  rather  dilapidated  condi- 
tion. The  stable  is  of  wooden  construction,  and  in  a  poor  state  of  repair. 
The  size  is  not  sufficient  to  accommodate  the  required  number  of  horses,  with 
a  resulting  crowding.  The  stables  are  poorly  ventilated  and  lighted.  One 
other  stable  is  rented  for  service  in  the.  western  part  of  the  city. 

The  wagons  are  constructed  with  strong  running  gears,  holding  the  steel 
tank  body,  having  a  capacity  of  2^  cubic  yards.  The  tank  body  is  hinged 
to  the  rear  axles  and  by  means  of  a  hoist  the  front  end  is  elevated,  dis- 
charging the  material  at  the  rear.  The  body  is  strengthened  by  arched  ribs 
across  the  top,  which  supports  a  sectional  canvas  cover.  In  addition  to  the 
wagons,  a  number  of  trucks  and  trailers  are  used.  The  trailers  are  equipped 
so  as  to  be  drawn  by  either  horses  or  tractors.  The  cars,  sixteen  in  number, 
used  for  transportation  of  the  garbage,  are  constructed  entirely  of  steel  and 
consist  of  a  semi-cylindrical  body  supported  upon  trunnions.  The  cars  have 
a  capacity  of  54  cubic  yards  or  35  to  40  tqns. 

The  ordinances  of  the  city  require  the  provision  by  householders  of 
suitable  water-tight  covered  receptacles  for  garbage  to  be  placed  in  accessible 
location  for  collectors.  These  ordinances  are  not  enforced,  especially  among 
the  poorer  classes  and  in  districts  having  foreign  population,  and  in  many 
cases  boxes,  buckets,  baskets,  etc.,  are  used,  which  are  not  suitable  recep- 
tacles. 

The  Municipal  Reduction  Plant  situated  at  Willow  is  about  two  miles 
south  of  the  southerly  corporation  limits  and  nine  miles  from  the  garbage 
loading  station.  It  occupies  a  tract  of  land  50  acres  in  area  and  is  situated 
in  the  Cuyahoga  River  Valley. 

The  buildings,  comprising  the  present  plant,  consist  of  the  Green  Garbage 
Building,  where  the  material  is  unloaded  from  the  cars;  the  Main  Building, 
which  contains  the  digesters  and  dryers,  to  which  is  connected  the  building 
containing  the  grease-separating  tanks  and  evaporators;  the  Percolating 
Building,  containing  the  grease-extracting  and  separating  machinery;  and 
the  Power  House,  containing  boiler  equipment  and  electric  generating  plant. 
The  plant,  as  originally  purchased  from  the  contractor,  was  installed  in 
1898  and  consisted  of  buildings  of  wood  construction.  The  present  buildings 
are  constructed  of  brick  and  steel. 

The  plant,  as  remodeled  by  the  city,  was  increased  in  capacity  at  the 
same  time  that  improved  equipment  was  installed  for  making  recoveries  of 
by-products.  The  old  method  of  unloading  the  garbage  from  tanks  by 
cranes  was  abandoned,  and  is  now  replaced  by  the  Green  Garbage  Building, 
where  the  garbage  from  the  cars  is  emptied  by  direct  dumping.  The  cars 
enter  the  building  on  an  elevated  track  and  are  dumped  by  means  of  chain 
hoists.    The  car  bodies  rotate  on  roller  bearings,  and  the  garbage  is  dis- 


Hospital  and  Health  Survey 


charged  on  the  concrete  floor  underneath  the  tracks.  The  garbage  in  the 
unloading  building  is  shoveled  upon  scraper  conveyors  and  discharged 
through  chutes  into  the  digesters,  of  which  there  are  33. 

After  digestion  for  a  period  of  six  hours,  by  using  70  to  80  pounds  of 
steam,  the  steam  pressure  is  applied  at  the  top  and  the  free  liquor  driven  off 
through  drains  at  the  bottom  to  the  settling  basins,  where  the  grease  rises 
to  the  top  and  is  skimmed  off.  The  liquor  from  the  bottom  of  the  settling 
tanks  is  pumped  to  an  evaporator  for  recovery  of  the  solids  in  solution. 

The  tankage  in  the  digester  is  removed  through  a  side  outlet  and  dis- 
charged into  a  conveyor  leading  to  the  driers.  The  driers  are  of  two  types, 
known  as  the  rotary  direct-heat  drier,  through  which  the  material  is  passed, 
eliminating  approximately  half  of  the  moisture  contained  in  the  tankage. 
It  is  then  passed  through  a  combination  steam  and  air  drier  to  remove  the 
remaining  moisture.  After  drying,  the  dried  material  is  conveyed  to  the 
extractor  building,  where  it  is  placed  in  percolators  and  the  grease  remain- 
ing is  recovered  by  percolation,  using  gasoline  as  a  solvent.  The  combined 
grease  and  gasoline  are  then  pumped  to  stills  where  the  solvent  is  evaporated, 
leaving  the  grease  ready  for  storage.  The  gasoline,  driven  off  from  the  stills, 
is  condensed  and  returned  to  storage  for  further  use.  The  tankage,  after 
percolation,  is  returned  to  the  driers  where  the  stick  or  concentrated  solids 
which  were  in  solution  coming  from  the  evaporator,  are  mixed  with  the 
fibrous  materia],  dried  and  then  passed  through  the  screening  and  grinding 
room  before  going  to  storage,  awaiting  sale  of  shipment. 

It  has  been  shown  by  figures,  based  on  reports  of  New  York  garbage- 
reduction  results,  that  one  ton  of  garbage  yields  the  following  products: 
from  the  grease  enough  glycerine  is  obtained  to  furnish  high  explosives  for 
ten  French  75-millimeter  shells,  and  soap  stock  sufficient  to  make  125  pounds 
of  laundry  soap;  from  the  tankage  or  fertilizer  enough  plant  food  in  the 
form  of  nitrogen,  phosphate  and  potash  is  secured  to  raise  ten  bushels  of 
wheat. 

Many  improvements  have  been  made  in  the  plant  since  it  was  originally 
purchased  by  the  city,  although  very  few  changes  have  been  made  in  the 
methods,  or  types  of  equipment  used,  during  the  past  ten  years. 

As  the  city  has  grown,  surrounding  the  plant,  there  has  been  increasing 
objection  raised  to  the  odors  given  off  by  the  processes  which  originate  from 
the  vents  on  the  digesters  and  from  the  gases  from  the  driers.  To  eliminate 
the  odor,  special  treatment  must  be  given  to  the  gases  carrying  odors,  which 
will  eliminate  the  nuisance.  Attempts  have  been  made  from  time  to  time 
to  deodorize  the  gases.  Plans  are  under  way  at  present  for  the  condensa- 
tion of  the  gases  or  vapors  given  off  by  the  digesters.  The  gases,  which  are 
of  large  volume,  coming  from  the  driers,  are  passed  through  a  scrubber  which 
consists  of  a  horizontal  brick  chamber,  where  they  are  subjected  to  water 
sprays  which  wash  and  condense  them.  The  efficiency  of  the  scrubber  is 
not  sufficient  to  eliminate  entirely  the  sweetish  or  caramel  odor  carried  by 
these  gases.     It  is  realized  by  the  city  that  steps  are  necessary  to  improve 


Environment  and  Sanitation  73 


the  present  conditions  at  the  plant,  both  from  the  standpoint  of  capacity 
and  for  the  elimination  of  undesirable  features  and  odors.  The  problem  is 
under  study  at  present. 

The  collection  and  disposal  of  dead  animals  were  formerly  handled  by 
the  city,  but  at  present  are  done  by  private  rendering  companies,  who  re- 
move and  dispose  of  the  large  animals  dying  within  the  city.  The  small 
dead  animals  are  disposed  of  with  the  garbage  at  the  Reduction  Plant. 
About  500  dead  dogs  are  collected  each  month. 

The  following  table  gives  the  quantity  of  garbage  collected  and  disposed 
of  during  the  past  ten  years;  also  the  cost  of  collection,  cost  of  disposal, 
receipts  from  sale  of  by-products  and  the  net  cost  for  collection  and  disposal. 

Table  Giving  Tons  of  Garbage  Handled,  Cost  of  Collection,  Cost  of 

Disposal,  Receipts  from  By-Products  and  Net  Cost  per 

Ton  for  Collection  and  Disposal 


Year 

Tons 
Garbage 

Cost 
Collection 

Cost 
Disposal 

Gross 
Income 

Net  Cost 
Collection, 
Disposal 

Net  Cost 
Per  Ton 

1910 

44,747 

$124,701 

$101,936 

$190,652.00 

$  35.985 

$0    804 

1911 

46,562 

139,456 

110,094 

189.894  00 

59,656 

1    281 

1912 

43,550 

139,379 

107,015 

151.162   00 

95.232 

2.187 

1913 

52,354 

143,672 

113,057 

157,705   00 

99.024 

!    891 

1914 

55,730 

165,858 

141,415 

195,221   00 

112,052 

2.011 

1915 

62,357 

181,556 

151,503 

224,691    00 

108,368 

1    738 

1916 

60,717 

195,266 

155,584 

304,072.00 

46.778 

0.77 

1917 

56,121 

236,035 

191.001 

292,745   00 

134,291 

2  393 

1918 

57,754 

304,183 

265,243 

437,842   00 

131,584 

2.278 

1919 

60.932 

355,175 

238,202 

295.361   00 

297.016 

4  874 

Ashes  and  Rubbish 

Previous  to  1906  ashes  and  rubbish  were  collected  entirely  by  private 
scavengers,  who  were  not  licensed  and  only  in  a  general  way  under  the 
supervision  of  the  Division  of  Health.  The  collections  were  not  regular, 
the  city  was  incompletely  covered  and  the  service  very  inefficient.  The 
material  was  disposed  of  by  dumping  on  vacant  lots,  side  streets  and  road- 
ways, or  in  such  places  as  it  could  be  disposed  of  without  causing  immediate 
complaint.  In  1906  the  city  undertook  the  collection  of  ashes  and  rubbish, 
in  order  to  eliminate  the  nuisance  caused  by  the  littering  of  streets  and  alleys, 
also  in  order  that  the  places  of  disposal  could  be  controlled  and  more  satis- 
factory results  obtained. 

The  work,  in  connection  with  the  collection  and  disposal  of  rubbish  and 
ashes,  is  under  the  direction  of  the  Commissioner  of  Streets,  whose  superin- 
tendents and  assistants  have  charge  of  the  work.  The  work  of  collection  is 
carried  on  by  the  same  organization  that  performs  such  work  as  is  done  in 
cleaning  the  streets,  and  men  and  teams  used  in  collection  are  also  employed 
at  times  in  street  cleaning. 

For  convenience  the  city  is  divided  into  six  districts  with  a  district  super- 
intendent in  charge  of  collection  service  as  well  as  street  cleaning.     Collee- 


74  Hospital,  and  Health  Survey 


tion  of  ashes  and  rubbish  is  provided  over  the  entire  city.  The  frequency  of 
collection  varies  and  work  is  not  regularly  scheduled.  In  some  sections 
there  is  a  collection  once  in  six  weeks,  in  other  sections  more  frequently. 
Collections  are  made  by  wagons  or  trucks.  Additional  trucks  have  been 
purchased  for  this  service.  The  wagons  are  of  the  bottom  dump  type, 
having  a  capacity  of  four  cubic  yards. 

Rules  and  regulations  have  been  adopted  by  the  Department  to  facilitate 
the  work,  which  require  householders  to  provide  suitable  receptacles  and  the 
tying  of  loose  refuse  into  bundles.  The  rules  have  been  difficult  to  enforce 
andxin  many  cases  are  not  complied  with. 

In  order  to  eliminate  the  dumping  of  waste  paper  and  at  the  same  time 
to  realize  upon  its  commercial  value,  the  Department  collects  waste  paper 
separately.  This  is  baled  and  sold.  This  applies  to  street  boxes  and  some 
of  the  larger  producers  of  waste  paper,  but  as  a  rule,  the  waste  paper  from 
residences  is  collected  at  the  same  time  as  the  ashes,  and  is  disposed  of  by 
dumping. 

The  disposal  of  rubbish  and  ashes  is  made  by  dumping.  The  location 
of  the  dumps  depends  upon  the  land  available  for  this  purpose.  In  many 
cases  dumps  are  made  available  by  owners  desiring  their  property  filled. 
There  are  twelve  principal  dumping  grounds  now  in  use. 

The  lake  front,  near  East  9th  Street,  is  the  largest  dump.  It  was  first 
begun  by  dumping  directly  into  the  lake,  after  which  a  breakwater  was 
constructed.  There  have  been  made  over  one  hundred  acres  of  land  from 
dumped  material  at  this  point.  The  principal  filling  has  been  with  ashes, 
street  cleaning  dirt  and  material  from  cellar  excavations. 

At  all  the  dumps  the  method  is  practically  the  same.  The  material  is 
dropped  from  the  wagons  or  trucks  at  the  edge  of  the  slope  and  then  shoveled 
over  the  edge  by  hand.  Considerable  complaint  is  made  of  nuisance  caused 
by  the  scattering  of  material,  and  the  odors  and  smoke  from  fires  in  many  of 
the  dumps.  These  have  generally  been  justified  and  their  abatement  is  the 
duty  of  the  Sanitary  Bureau. 

The  following  table  gives  the  quantity  of  ashes  and  rubbish  as  collected 
during  the  past  five  years,  together  with  the  cost  for  labor  and  teams  for  the 
service,  as  reported  by  the  Division  of  Streets : 


Year 

Cubic  Yards 
Collected 

Cost 

Cost  Per 
Cubic  Yard 

1915 

318,390 

$181,296.13 

$0.57 

1916 

356,336 

209,920.85 

0.59 

1917 

335,769 

227,249.03 

0.677 

1918 

477,967 

277,650.03 

0.58 

1919 

495,834 

284,286.26 

0.5734 

The  above  cost  includes  only  expenditures  for  teams  and  labor,  and  not 
any  fixed  charges,  maintenance,  overhead  or  allowance  for  use  of  trucks 
owned  by  the  city. 


Environment  and  Sanitation  75 

The  Director  of  Public  Service  is  now  having  a  complete  study  and  sur- 
vey made  in  order  to  determine  what  steps  should  be  taken  to  remedy  and 
improve  the  conditions  of  collection  and  disposal  of  garbage,  ashes  and  rub- 
bish. This  survey  and  study  considers  what  steps  can  be  taken  to  improve 
the  collection  service  and  at  the  same  time  reduce  the  cost  for  long  hauls 
and  the  present  expensive  methods  of  handling. 

The  investigation  and  report  will  cover  the  various  methods  necessary 
for  collection,  delivery  and  disposal  of  ashes,  rubbish  and  garbage,  including 
substantially  the  following  subjects: 

1.  Analysis  of  data  contained  in  the  records  of  the  Department  of 
Public  Service  with  reference  to  collection  of  garbage,  ashes  and  rubbish. 

2.  Study  of  population  and  future  growth  of  the  city  to  provide  for  a 
comprehensive  plan  for  future  needs. 

3.  Comparison  of  various  methods  of  collection  and  types  of  equipment 
suitable  to  systematize  that  service  for  the  City  of  Cleveland. 

4.  Comparison  of  various  methods  of  disposal  for  different  classes  of 
waste,  adaptable  to  Cleveland's  needs. 

5.  Outline  of  essential  features  necessary  to  produce  a  sanitary  and 
economical  collection  and  disposal  of  garbage,  ashes  and  rubbish  by  various 
methods. 

6.  Quantities  and  plant  capacities  with  proper  allowance  for  future 
growth  and  local  conditions. 

7.  The  advisability  of  collection  and  disposal  of  waste  in  a  central  plant 
as  compared  with  a  number  of  plants. 

8.  Determination  of  and  advisability  of  a  number  of  transfer  stations 
and  methods  of  transfer  and  delivery  of  material  to  points  of  disposal. 

9.  Comparison  of  costs  by  various  methods  of  collection  and  disposal, 
giving  capital  cost,  annual  operating  and  maintenance  charges,  also  the 
total  plant  charges  and  revenues. 

10.  Recommendations.  A  discussion  of  the  various  projects  adaptable 
to  Cleveland,  with  recommendations  covering  the  most  feasible  plan  for  the 
collection  and  disposal  of  waste  from  a  sanitary  and  economical  standpoint. 

The  complete  study,  as  outlined  above,  will  take  into  account  all  prac- 
ticable plans  that  might  be  adopted,  each  developed  so  that  the|most  feas- 
ible plan  can  be  recommended,  taking  into  account  the  sanitary|and  eco- 
nomical advantages  to  be  gained  to  take  care  not  only  of  present  conditions 
but  the  future  needs  of  the  city. 


Hospital  and  Health  Survey 


A  "Front  Door''  on  a  Cleveland  Alley. 
The  pile  is  made  up  of  mixed  gar- 
bage and  rubbish. 


Stable  rejvse  on  an  alien  in  Cleveland's  most  congested  quarter.    In  the  Spring  a  natural 
lira  ding  place  for  millions  of  flies. 


Environment  and  Sanitation 


77 


Food  and  rubbish.      The  wintzr  collection  of  a  Clevel  ind  b  ickyard. 


Next  door  to  a  grocery  store  in  Cleveland's  congested  district. 


78  Hospital  and  Health  Survey 

Street  Cleaning 

The  work  of  cleaning  the  streets  is  under  the  direction  of  the  Street  Com- 
missioner and  directly  under  one  of  the  deputy  commissioners.  The  work 
is  carried  on  by  district  gangs,  who  are  in  charge  of  the  collection  and  dis- 
posal of  ashes  and  rubbish.  Men  and  teams  interchange  for  each  class  of 
work. 

The  city  is  divided  into  six  districts  for  refuse  collection,  with  a  foreman 
in  charge  of  each  district.  The  city  is  divided  into  three  districts  for  street 
cleaning,  by  a  "white  wing"  patrol,  with  a  foreman  of  "white  wings." 

The  catch  basin  cleaning  under  the  direction  of  a  foreman,  includes  the 
whole  city,  except  for  parks  and  boulevards,  which  are  under  another  de- 
partment. 

There  is  also  a  foreman  in  charge  of  equipment,  including  wagons,  trucks 
and  automobiles.  In  addition,  there  is  the  office  force  and  a  corps  of  inspec- 
tors and  investigators  of  complaints.  To  each  foreman  is  assigned  such 
assistants,  subforemen,  laborers  and  teams  as  required. 

There  are  609  miles  of  paved  streets  in  the  city,  and  the  methods  of  clean- 
ing consist  principally  of  "white  wing"  patrol,  pickups  and  flushing.  The 
cleaning  of  streets  in  the  downtown  section  and  the  streets  at  more  impor- 
tant intersections  is  done  principally  by  "white  wings." 

The  patrol  districts  are  not  established,  and  the  number  of  "white 
wings"  employed  varies  with  the  funds  available  for  cleaning  work,  with 
the  result  that  the  thoroughness  of  cleaning  varies.  No  record  is  kept  of 
the  areas  cleaned  daily  or  left  uncleaned,  and  the  records  are  made  up  by 
assuming  that  each  "white  wing"  has  cleaned  his  allotted  area  at  least  once 
a  day,  irrespective  of  the  work  actually  accomplished.  The  work  is  reported 
for  "great  squares,"  which  contain  10,000  square  feet  each. 

The  following  table  gives  the  work  of  the  "white  wing"  patrol  and  the 
cost  of  it  for  the  past  five  years,  as  given  in  reports  of  the  Division  of  Streets. 


Year 

Squares 
Cleaned 

Total 
Cost 

Average  Cost 
Per  Square 

1915 

438,606 

$119,421.15 

$.2723 

1916 

448,387 

104,327.78 

0.2326 

1917 

300,083 

135,389.83 

0.4512 

1918 

312,094 

105,358.34 

0.3375 

1919 

313,497 

139,055.72 

0.4435 

The  above  cost  covers  only  labor  and  teaming,  and  does  not  include 
any  fixed  charges,  maintenance  or  overhead. 

The  method  of  pickups,  in  addition  to  flushing,  is  used  on  streets  not 
included  in  the  "white  wing"  areas.  The  men  and  equipment  used  in  ash 
and  rubbish  collection  are  used  largely  in  pickup  work,  which  consists  prin- 


Environment  and  Sanitation  79 


cipally  in  cleaning  gutters  and  picking  up  the  accumulation  of  dirt  on  the 
streets.     This  method  is  used  largely  in  outlying  and  residential  streets. 

The  following  table  gives  the  work  by  the  pickup  method  as  reported 
for  the  past  five  years,  including  the  labor  and  teaming  cost  for  the  work. 


Year 

Squares 
Cleaned 

Cost 

Per  Square 
Average 

1915 

93,993 

$69,544.78 

$0.74 

1916 

112,091 

75,073.04 

0.67 

1917 

75,342 

78,497.82 

1.04 

1918 

84,653 

69 , 563 . 54 

0.82 

1919 

85,624 

75,967.96 

0  89 

One  of  the  principal  methods  of  cleaning  is  by  flushing  the  streets,  which 
is  employed  occasionally  in  the  warm  months  of  the  year,  on  the  main 
thoroughfares.  The  city  has  two  motor  driven  flushers  employed  in  this  work 
and  eleven  street  car  flushers,  rented  from  the  street  railway  company. 

The  motor  driven  flushers  are  used  in  the  city  as  a  whole,  and  assigned 
for  work  as  needed.  The  street  car  flushers,  when  used,  are  operated  on 
streets  having  trackage. 

Aside  from  the  cleaning  done  by  "white  wing"  patrols,  the  most  effective 
work  is  done  by  flushing,  although  this  is  not  extended  so  as  to  cover  terri- 
tory outside  the  main  thoroughfares. 

The  following  table  gives  the  work  and  costs  for  flushing  during  the  past 
five  years. 


Year 

Squares 
Flushed 

Cost 

Average  Cost 
Per  Square 

1915 

329,319 

$36,351.93 

$0.11 

1916 

310,384 

34,971.99 

0.113 

1917 

163,168 

20,250.47 

0.124 

1918 

247,306 

13,966.63 

0.056 

1919 

336,340 

18,165.68 

0.054 

During  1919  there  was  reported  flushed  by  street  car  flushers  251,097 
squares  at  a  cost  of  $12,676.25,  or  an  average  cost  of  $0.0505  per  square; 
and  by  motor  flushers  85,243  at  a  cost  of  $5,489.43,  or  an  average  of  $0.0644 
per  square. 

The  above  costs  include  the  rental  paid  the  Street  Railway  Company 
but  do  not  include  any  fixed  charges,  maintenance,  overhead  or  cost  for  water, 
which,  if  added  to  the  total,  would  increase  considerably  the  cost  for  motor 
flushers. 

The  following  table  gives  the  direct  expenses  during  the  year  1919  for 
labor  and  team  hire  in  the  Street  Cleaning  Division,  but  not  including  fixed 
charges  or  replacements: 


80                                                                          Hospital  and  Health  Survey 

Expenditures  of  the  Division  of  Street  Cleaning  During  the 

Year  1919 

Household  refuse  collection $284 ,  286 .  26 

White  wing  patrol... _ 139 ,  055 .  72 

Pickup  gangs 75  ,  967 .  96 

Supervision  and  inspection 58,  734.08 

Catch  basin  cleaning.. _ 39 ,  994 .  38 

Maintaining  dumps 29 ,  486 .  93 

Mechanical  repairs 2  7 , 233 . 90 

Watchman 25 ,  695  .  40 

Market  cleaning 15  ,  786 .  56 

Street  car  flushing 12 ,  676 .  25 

Waste  paper.. _ 10 ,  508 .  70 

Motor  flushing 5 ,  489 .  43 

Snow  removal 2  ,  599  99 

Cinders _ _ 799.03 


Total $728 ,  314 .  59 

Labor  payroll 526 ,  650 .  49 

Team  payroll _ 192  ,  998 .  85 

Rent  of  car  flushers 8 ,  665  .  25 


$728,314.59 


The  insignificant  suna  charged  to  cost  of  snow  removal  in  1919  may  be 
the  explanation,  it  cannot  be  offered  as  the  excuse  for  the  intolerable  filth 
and  neglect  of  the  streets  during  the  winter  of  1919-20. 

General 

The  studies,  now  being  made  for  the  Director  of  Public  Service,  of  the 
the  city  services  for  street  cleaning  and  the  collection  of  ashes,  rubbish  and 
garbage,  will  show  where  improvements  can  be  made. 

One  of  the  chief  handicaps  of  the  city  has  been  the  limited  funds  avail- 
able for  conducting  the  work,  with  continually  increasing  cost  for  labor  and 
equipment. 

If  systematic  and  efficient  work  is  to  be  carried  on,  the  following  requisites 
are  necessary  for  success: 

1.  A  sufficient  appropriation. 

2.  An  efficient  organization. 

3.  Sanitary  and  economical  methods  of  work. 

4.  Cooperation  on  the  part  of  the  public. 

Appropriation  is  necessary  to  cover  the  cost  of  the  work  to  be  done,  and 
the^quantity  of  work  accomplished  will  depend  on  the  fund  available,  pre- 


Environment  and  Sanitation  81 

viding  it  is  efficiently  used.  An  efficient  organization  will  develop  effective 
and  economical  methods  of  work.  Sanitary  and  economical  methods  of 
work  will  be  obtained  from  study  and  application  of  studies,  after  compari- 
son of  records  and  unit  costs  of  the  work  by  various  methods. 

The  cooperation  of  the  public  can  be  obtained  by  education  and  regula- 
tions consistently  and  uniformly  enforced.  Results  will  be  more  readily 
obtained  when  efficient  and  satisfactory  service  has  been  rendered.  All  four 
requisites  are  dependent  on  each  other  to  obtain  the  maximum  degree  of 
success. 

From  the  investigation  made  it  is  evident  that  very  little  intensive  study 
has  ever  been  given  the  street  cleaning  work  in  the  city. 

A  comparison  of  the  work  done  in  Cleveland  with  that  of  other  cities  will 
show  that  less  work  is  given  here  to  effective  street  cleaning  than  in  the  other 
cities  of  comparable  size;  at  the  same  time,  the  annual  expenditure  for  the 
work  is  less  than  in  other  cities.  The  result  is  that  many  streets  are  seldom 
cleaned  thoroughly,  and  many  receive  only  such  work  as  is  given  by  the 
pickup  method  in  cleaning  gutters  a  very  few  times  per  year,  a  wholly  in- 
adequate service. 

From  the  studies  made  it  has  developed  that  the  records  of  the  Street 
Cleaning  Department  are  not  complete  as  to  the  actual  work  performed, 
and  unit  costs  for  conducting  the  different  parts  of  the  work  have  never  been 
developed.  These  are  essential  to  permit  the  official  in  charge  to  obtain  the 
information  necessary  for  the  proper  work  control  and  administration. 

The  Director  of  Public  Service  is  now  planning  for  necessary  changes  in 
organization  to  provide  assistants  in  the  Street  Cleaning  Department.  There 
will  be  systematic  planning  of  work  and  a  system  for  record  and  unit  cost 
keeping  of  the  several  activities  of  the  Department.  These,  when  installed, 
should  greatly  assist  in  the  direction  of  the  Department. 

In  one  city,  where  studies  were  made,  it  was  found  that  out  of  an  annual 
expenditure  of  $350,000  at  least  one-third  of  the  amount  was  wasted,  due  to 
inefficient  work  and  inefficient  methods. 

The  city  of  Washington,  by  adoption  of  methods  in  planning  and  estab- 
lishment of  complete  record  and  unit  cost  keeping,  was  able  to  reduce  the 
cost  of  street  cleaning  30  per  cent,  and  at  the  same  time  to  do  more  effective 
work.  Washington,  during  the  summer  months,  washes  each  street  on  an 
average  of  once  for  each  two  and  a  half  days.  New  York  City  has  established 
methods  and  standardized  the  street  cleaning  work  so  that  every  important 
or  congested  thoroughfare  is  cleaned  by  flushing,  by  squeegee  machine,  or  by 
sprinkling  and  sweeping,  at  least  once  in  every  24  hours. 

With  the  shortage  of  funds  for  municipal  work  in  Cleveland  the  establish- 
ment of  the  methods  proposed  should  assist  the  officials  in  charge  to  accom- 
plish the  greatest  amount  of  work  with  the  funds  available. 

It  is  recommended  that: 

The  steps  being  taken  by  the  city  in  having  studies  made  to  determine  improvements 


82  Hospital  and  Health  Survey 


necessary  for  the  collection  and  disposal  of  garbage,  ashes  and  rubbish  be  approved.    They 
should  permit  the  adoption  of  improved  methods  equal  to  those  found  in  any  city. 

Special  attention  be  given  in  studies  now  being  made  to  eliminate  so  far  as  possible 
cause  for  complaint  of  nuisance,  due  to  odors  from  dumps  or  disposal  plants,  either  by 
more  attention  to  control  of  dumps  or  by  the  adoption  of  other  means  for  disposal. 

It  is  essential,  in  order  to  control  properly  and  carry  on  efficiently  the  work  of  street 
cleaning  to  plan,  schedule  and  keep  records  and  unit  costs  of  the  work.  The  step  being 
taken  by  the  Director  of  Public  Service  to  provide  for  an  assistant  to  the  Commissioner, 
who  will  develop,  install,  and  keep  records  and  unit  costs  of  the  several  activities  of  the 
Department  will  be  one  of  the  most  progressive  steps  taken  since  the  organization  of  the 
Department.  The  work  done  should  include  studies  of  the  work  actually  performed,  to 
determine  the  advantages  to  be  gained  by  making  changes  and  improvements,  and  should 
furnish  the  Director  and  Commissioner  with  detailed  information  necessary  for  the  work, 
the  control  and  the  management  of  the  Department. 

The  Collection  of  ashes  and  rubbish  should  be  scheduled  so  that  regular  and  syste- 
matic collections  are  made.  Thus  residents  can  plan  on  the  time  when  collections  will 
be  made  and  have  materials  in  proper  condition  for  the  collector.  This  will  permit  a 
better  enforcement  of  regulations  and  will  eliminate  complaints. 


Environment  and  Sanitation  83 


Flies   and   Mosquitoes 

THERE  is  no  directory  or  list  of  stables  and  no  census  of  horses  or  cattle 
stabled  in  Cleveland,  kept  at  the  Division  of  Health  or  otherwise  avail- 
able. There  are  no  regulations  enforced  dealing  with  the  collection 
and  disposal  of  animal  manure  so  as  to  control  fly  breeding  in  Cleveland. 
Manure  piles,  fresh  and  of  long  standing,  were  found  commonly  in  the  resi- 
dential regions  in  the  poorer  quarters  of  town  within  common  fly  range  of 
unscreened  food  stores  and  restaurants.  Only  one  of  several  score  of  privies 
inspected  on  both  West  and  East  Sides  of  the  city  in  the  regions  supplied  or 
not  supplied  with  sewers,  was  found  to  be  so  constructed  as  to  give  any 
reasonable  expectation  that  flies  could  be  kept  away  from  access  to  freshly 
deposited  human  waste  or  to  the  privy  vault  itself. 

Only  one  privy  above  noted  was  found  with  seat  covers,  or  if  seat  covers 
were  provided,  they  were  so  made  and  used  as  to  be  of  no  use  in  excluding 
flies  from  the  vault.  Doors  were  open  or  cracked.  Windows  in  privy 
closets  not  screened,  fecal  deposits  on  the  seat,  on  the  floor  and  overflowing 
from  the  pit  on  the  ground  without,  were  frequently  found.  Uncovered 
garbage  cans  and  uncollected  accumulations  of  garbage  are  common  even  in 
warm  weather. 

Under  these  conditions  for  which  the  Sanitary  Bureau  of  the  Division  of 
Health  must  be  held  responsible,  it  is  unnecessary  to  go  into  any  detail 
as  to  the  fly  nuisance  in  Cleveland.  "  Swat-the-fly "  campaigns,  or  efforts 
to  teach  children  and  householders  to  kill  flies  and  reduce  disease  are  mere 
waste  of  time.  Until  breeding  places  of  flies,  that  is,  exposed  fresh  animal 
excreta  are  controlled  attacks  upon  the  fly  upon  the  wing  are  vain.  Screen- 
ing is  necessary,  and  except  in  cheap  eating  and  food  stores,  which  seem  to 
escape  inspection,  is  fairly  well  accomplished.  Control  of  water  and  milk 
and  education  of  mothers  are  responsible  for  the  low  incidence  of  enteric 
disease  in  Cleveland,  and  not  control  of  the  fly. 

Neither  mosquitoes  nor  malaria  are  sufficiently  common  to  require  any 
special  attention.  Mosquitoes  breed  more  or  less  according  to  the  character 
of  the  breeding  season,  but  do  not  amount  to  a  serious  nuisance  within  the 
city  limits.  Only  twelve  cases  of  malaria  were  reported  to  the  Division  of 
Health  in  the  years  1916-19  inclusive. 


RECOMMENDA  TIONS 

It  is  recommended  that: 

The  Sanitary  Bureau  maintain  supervision  over  the  horse  and  cow  stables  in  Cleve- 
land and  with  such  authority  as  can  be  found  in  the  Sanitary  Code,  require  the  protection 
and  periodic  removal  of  manure  so  that  fly  breeding  may  be  reduced  or  largely  prevented. 

All  privies  in  Cleveland  be  so  constructed  and  maintained  after  well-known  methods 
as  to  prevent  access  of  flies  to  human  excreta. 


84  Hospital  and  Health  Survey 

The  holding  of  garbage  in  covered  tight  metal  containers  and  the  removal  of  garbage 
at  least  twice  a  week  from  April  to  November  be  required  throughout  the  city. 

An  ordinance  be  passed  and  enforced  forbidding  such  collections  of  water  as  are 
likely  to  permit  the  breeding  of  mosquitoes.  (For  model  ordinance  see  U.  S.  Public  Health 
Reports,  1920,  April  2,  page  829.) 


Environment  and  Sanitation  85 

Smoke  and  Its  Prevention 

ONE  might  honestly  report  after  a  careful  survey  of  the  city  and  its  public 
and  private  agencies,  that  nothing  of  a  practical  nature  is  being  done 
or  even  attempted  in  the  field  of  smoke  prevention.  Cleveland  enjoys 
an  amazingly,  and  one  would  be  tempted  to  say,  an  intolerably  polluted  air 
all  the  year  round.  The  reason  is  not  that  such  air  pollution  as  Cleveland 
tolerates  cannot  be  abated,  or  that  similar  disgraceful  interference  with  health 
and  the  enjoyment  of  life  has  not  been  controlled  elsewhere. 

"There  is  nothing  impossible  or  wonderful  about  the  smokeless  combus- 
tion of  even  Pittsburgh  coal,  provided  the  proper  methods  are  applied  and 
the  ordinary  precautions  taken." 

Such  was  the  opinion  expressed  by  the  competent  group  of  engineers 
responsible  for  Bulletin  8  of  the  Smoke  Investigation  of  Pittsburgh  in  1914. 

Another  statement  in  the  same  publication  is  so  directly  applicable  to 
Cleveland  that  it  will  bear  quoting: 

"A  small  group  of  men  control  the  plants  which  produce  80%  of  the 
smoke  of  the  district.  The  solution  of  Pittsburgh's  smoke  problem  lies  in 
inducing  these  men  to  apply  the  best  modern  engineering  practice  to  the 
combustion  of  fuel  in  their  plants." 

If  the  Chamber  of  Commerce  of  Cleveland  could  convince  the  manu- 
facturing and  commercial  interests  of  the  city  that  their  indifference  to  the 
smoke  nuisance  is  responsible  for  a  very  large  amount  of  sickness  in  the 
city,  and  that  the  antiquated  equipment  and  careless  administration  of 
their  plants  which  cause  this  nuisance,  cause  them  and  the  city  each  year 
a  cash  loss  of  several  times  the  amount  of  the  total  annual  Community  Fund, 
or  at  a  modest  estimate  about  $20,000,000,  action,  civic  and  individual,  would 
probably  follow  with  gratifying  rapidity. 

It  needs  no  visiting  surveyor  to  tell  the  people  of  Cleveland  what  their 
senses,  sight,  touch,  smell  and  taste  must  convince  them  of  daily,  that  the 
air  of  their  city  is  unfit  for  human  consumption  just  as  their  sewage-polluted 
water  was  a  few  years  ago. 

Since  no  quantitative  observations  of  air  pollution  in  Cleveland  could  be 
discovered,  a  brief  series  of  soot-fall  studies  was  made  during  July  and  August, 
the  months  of  the  year  when  the  degree  of  air  pollution  from  soot  is  probably 
at  its  lowest.  As  compared  with  certain  English  cities  and  with  Pittsburgh 
(Bulletin  8,  Smoke  Investigation,  page  22)  probably  Cleveland's  nearest 
former  competitor  in  smoke  production,  in  this  country,  Cleveland  now 
deposits  a  few  tons  per  square  mile  per  annum  less  of  combustion  products 
than  did  the  other  cities  (London  and  Pittsburgh)  when  they  were  at  the 
height  of  their  nuisance.  In  recent  years  both  the  English  cities  and  Pitts- 
burgh have  made  improvements  in  this  direction.  Cleveland  is  supine  in 
the  face  of  increasing  air  pollution. 


86  Hospital  and  Health  Survey 


The  following  statement  represents  reports  received  from  the  firm  of 
consulting  engineers  (The  James  H.  Herron  Co.)  engaged  to  make  soot-fall 
studies  for  the  Survey. 

Purpose  of  Examination 

The  purpose  of  the  examination  was  to  determine  the  amount  of  matter 
present  in  the  atmosphere  in  samples  taken  from  a  number  of  stations 
throughout  the  city  of  Cleveland,  also  to  get  data  which,  if  possible,  may  be 
compared  with  the  work  done  in  other  communities  on  this  same  subject. 

Extent  of  Examination 
Observations  were  made  at  four  stations  situated  as  follows: 

1.  The  roof  of  the  Superior  Peanut  Co.  building,  situated  adjacent  to  the 
Huron  Road  Hospital.  This  place  was  chosen  owing  to  the  fact  that  a  roof 
position  on  the  hospital  was  not  available. 

2.  The  roof  of  St.  Alexis  Hospital,  Broadway  and  McBride  Avenue. 

3.  The  roof  of  the  Babies'  Dispensary,  2500  East  35th  Street. 

4.  The  roof  of  Mt.  Sinai  Hospital,  1800  East  105th  Street. 

It  was  decided  that  the  samples  collected  from  these  locations  would  be 
.sufficiently  representative  for  general  comparative  purposes. 

Apparatus  Used 

The  apparatus  used  was  composed  of  a  gauge  of  four  square  feet  in  area 
and  was  similar  to  the  standard  gauge  used  in  the  investigation  of  atmos- 
pheric pollution  in  the  city  of  London  in  the  years  of  1914  and  1915.  This 
gauge  was  deemed  most  satisfactory  for  this  purpose. 

The  Analyses 

The  deposit  was  collected  at  the  end  of  each  month  and  the  analyses  as 
reported  made  at  the  end  of  each  of  the  two  months,  June  26  to  July  26  and 
July  26  to  August  26.  The  deposit  was  analyzed  for  tar,  ash,  fixed  carbon 
and  iron  oxide.  This  followed  the  order  in  which  the  analyses  were  made  in 
connection  with  the  smoke  investigation  of  the  city  of  Pittsburgh,  the  result 
of  which  was  published  in  Bulletin  No.  8  of  Smoke  Investigation.  The  re- 
sults given  in  this  analysis  are  comparable  with  the  results  obtained  in  Pitts 
burgh. 


Environment  and  Sanitation 


87 


Observations,  June  26  to  July  26,  1920 


At  Huron  Road 
Hospital 


At  Babies'  Dispensary 
and  Hospital 


At  St.  Alexis 
Hospital 


Soot  Fall  per  Square  Foot  per  Month 

1.4940  Grams  1.5530  Grams  1.6514  Grams 


At  Mt.  Sina. 
Hospital 


.9436  Grams 


Per  Cent  Composition  of  Deposit 

Tar. 2.82  2.29  55 

Fixed  Carbon 32.65  31.26  34.19 

Ash 64.55  66.45  65.26 

Fe2  O.s   in  Deposit ......  6.67  11   04  10.82 

Deposit  in  Tons  Per  Square  Mile  Per  Year 

Total  Deposit 550.94                       592.70  608.98 

Tar 13.55                         13 .58  3  34 

Fixed  Carbon 178.59                       185.40  208.24 

Ash _. 355.80                       393.72  397.40 

Fe?  O3  in  Deposit 36.75                        65.45  65.70 


2.86 
31.80 
65.34 

15.75 


347.97 

9.95 

110.66 

227.36 

64.80 


Observations,  July  26  to  August  26,  1920 


At  Huron  Road 
Hospital 


At  Babies'  Dispensary 
and  Hospital 


At  St.  Alexis 
Hospital 


Soot  Fall  per  Square  Foot  per  Month 

3.7775  Grams  2.7259  Grams  1.9995  Grams 


At  Mt.  Sina 
Hospital 


.8421  Grams 


Per  Cent  Composition  of  Deposit  (July  26  to  August  26  1920) 

Tar... 3.33                           3.61  3.76  4.43 

Fixed  Carbon 28.94                         32.15  33.33  32.40 

Ash 67.73                         64.24  62.91  63.17 

Fe 2  O3  in  Deposit 23.00                         17.90  13  38  16.58 

Deposit  in  Tons  per  Square  Mile  per  Year 

Total  Deposit 1392.91                     1005.15  737.31  310.52 

Tar 46.39                        36.32  27.66  13.75 

Fixed  Carbon.... 403.11                       323.15  245.74  100  61 

Ash..... 943.41                       645.68  463.91  196.16 

Fe2  O3   in  Deposit ,           320  37                      179  92  98.65  51.48 

Average  Deposit  in   Tons  per  Square  Mile  per    Year  Calculated  on   Observations 

June  26  to  August  26,  1920 

Total  Deposit 971.73                       798.93  673.15  329.50 

Tar 29.97                        24.95  27.50  11.85 

Fixed  Carbon 290.85                       254.28  226.99  105.63 

Ash „            649.61                       519.70  430.65  211.76 

Fe*  O3  in  Deposit. 178  56                       122.58  82.18  58.14 


Hospital  and  Health  Survey 


At  times  in  the  past  in  both  Pittsburgh,  Pennsylvania  and  London, 
England,  deposits  of  more  than  1,000  tons  per  square  mile  per  year  have 
been  recorded  for  periods  of  a  month  or  more.  For  details  of  relative  pro- 
portions of  the  solid  components  of  the  deposits  in  Cleveland  and  in  other 
cities  here  and  abroad  the  reader  is  referred  to   original  documents. 

There  is  a  not  inconsiderable  volume  of  air  pollution  due  to  volatile  sub- 
stances, the  sulphurous  acid  and  other  fumes  commonly  found  accompanying 
heavy  soot  fall,  but  precise  information  as  to  the  extent  of  such  harmful 
substances  must  await  studies  of  greater  extent  than  the  Survey  could  under- 
take in  the  time  and  with  the  money  at  its  disposal. 

Admitting,  if  only  for  the  sake  of  argument,  that  Cleveland  suffers  from 
an  extreme  case  of  dirty  air,  and  certainly  the  valuable  reports  of  the  Cleve- 
land Chamber  of  Commerce  in  recent  years  should  leave  one  in  no  doubt 
as  to  the  extent  of  financial  loss  to  persons  and  property  justly  attributable 
to  this  public  nuisance,  it  may  reasonably  be  asked  what  is  the  interest  of 
the  Hospital  and  Health  Survey  in  air  pollution. 

Briefly,  diseases  of  the  upper  respiratory  tract  are  increased  by  the  irri- 
tation of  coal  dust  in  the  air,  and  pneumonia  is  to  some  degree  increased  in 
frequency  and  severity  by  pollution  of  the  air  with  coal  dust.  Diminution 
of  sunlight  reduces  the  bactericidal  action  of  this  most  sanitary  free  agent. 
A  diminution  of  sunshine  which  is  familiar  to  every  Clevelander  for  all  the 
cool  and  winter  months  of  the  year,  can  be  shown  to  permit  an  increase 
of  bacteria,  both  pathogenic  and  harmless,  in  the  air.  "When  the  air  is 
dirty  it  is  hard  to  get  the  streets,  the  yards,  the  clothes,  the  people  clean," 
and  certainly  bodily,  personal  and  home  cleanliness  are  important  safeguards 
to  health.  The  baleful  psychical  effect  of  smoky,  dark  and  dirty  air  on 
human  health  and  happiness  has  been  emphasized  by  observers  in  England 
and  in  Pittsburgh. 

In  an  ever  wider  radius  from  the  main  centers  of  smoke  production, 
plant  life,  tree  life  and  especially  the  life  of  evergreen  trees  and  shrubs  is 
being  destroyed.  The  constant  deposit  on  the  ground  of  coal,  tar,  ash, 
cinder  and  unburned  carbon  destroys  the  scant  fertility  of  grass  plots  in 
yards  and  parks  in  many  parts  of  the  city.  It  must  be  admitted  that  where 
the  air  contains  such  pollution  as  to  make  life  unbearable  for  vegetation,  we 
must  look  sharply  to  protect  the  lives  and  health  of  the  human  flowers,  the 
children  who  for  large  numbers  of  the  population,  have  no  escape  from  the 
soot-laden  air. 

True,  there  is  a  Commissioner  of  Smoke  Prevention  appointed  by  the 
Mayor.  He  has  an  office  in  the  City  Hall.  He  receives  a  salary  of  $2,000.00 
a  year.  His  preparation  and  education  for  this  highly  technical  position  has 
been  that  of  a  fireman  on  a  locomotive.  He  has  had  no  technical  training, 
he  has  no  books  or  laboratory  or  instruments  of  precision,  or  experience  in 
the  practices  used  elsewhere  to  measure  the  extent  of  smoke  nuisance,  to 
prepare  strong  cases  and  arguments  in  court,  or  to  carry  on  effective  educa- 
tion among  plant  owners,  engineers,  firemen,  etc.  One  of  his  functions  is 
to  pass  upon  and  issue  licenses  for  plants  for  heating,  power  and  other  coal 
and  oil  consuming  furnaces,  all  of  which  he  does  as  a  part  of  a  purely  formal 


Environment  and  Sanitation  89 

clerical  routine,  without  inquiry  as  to  the  adequacy  of  draft  or  other  equip- 
ment, such  as  mechanical  stokers,  etc.,  which  will  render  smoke  nuisance  at 
least  less  likely.  There  are  four  inspectors  also  appointed  by  the  Mayor, 
and  not  through  civil  service  examination,  receiving  $1,375.00  a  year  and  a 
stenographer  at  $900.  In  the  same  office  at  a  desk  adjacent  to  that  of  the 
Commissioner  of  Smoke  Prevention  is  an  employe  of  eight  of  the  railroads 
operating  within  the  city  limits.  He  receives  $3,900.00  a  year.  His  experi- 
ence was  formerly  locomotive  fireman  and  later  foreman  responsible  for 
locomotive  equipment  on  one  of  the  important  railway  systems.  His  func- 
tion is  to  serve  the  railroads  which  pay  him,  so  that  observations  made  by 
the  field  inspectors  (or  by  himself)  of  wasteful  smoke  nuisance  from  loco- 
motives may  be  promptly  reported  to  the  company  concerned,  and  the 
offending  fireman  may  be  reprimanded,  suspended  or  dismissed.  As  a  matter 
of  fact,  the  saving  to  the  railroads  in  fuel  cost,  as  the  result  of  disciplinary 
action  directed  against  careless  firemen,  more  than  offset  the  expense  of  their 
smoke  inspection  service.  There  is  probably  some  benefit  to  the  city  from 
this  servant  of  railroad  operating  efficiency,  but  locomotive  smoke  plays  but  a 
small  part  in  the  general  curtain  of  dirt  which  the  plant  chimneys  throw  over 
the  city. 

Of  the  four  inspectors  in  city  employ,  one  is  assigned  to  the  east,  one  to 
the  west,  one  to  the  downtown  section  of  the  city  and  one  is  on  railroad 
duty  to  assist  the  railroad  employe  above  referred  to.  Reports  of  smoke 
nuisance  are  based  on  duration  and  density  as  measured  by  the  Pungleman 
chart.  No  action  follows  violation  of  the  city  ordinance.  The  reasons  given 
for  failure  to  prosecute  (there  have  been  no  prosecutions  for  many  months) 
are  that  there  is  not  only  no  public  opinion  in  support  of  vigorous  action  but 
that  there  is  active  opposition  to  any  interference  with  industry  in  the 
interest  of  clean  air,  and  further  that  cases  are  continued  in  the  Municipal 
Court  until  all  value  of  action  is  lost  and  there  is  lacking  reasonable,  judicial 
support  for  the  objectives  of  the  city  officials. 

Conditions  of  smoke  nuisance  are  reported  by  responsible  observers  both 
in  and  out  of  the  city  employ  to  be  much  worse  than  they  were  under  the 
administration  of  Mayor  Baker,  when  the  Commissioner  of  Smoke  Preven- 
tion, a  trained  civil  engineer  at  a  salary  of  $4,000.00,  and  with  a  force  of  com- 
petent inspectors,  made  an  intelligent  and  effective  attack  on  the  problem. 
The  resentment  and  opposition  of  prominent  men  against  whose  plants 
action  was  taken,  resulted  in  the  discontinuance  of  an  efficient  service 
by  cutting  off  the  appropriation. 

A  complication  which  adds  somewhat  to  the  problem  of  the  plant  manager 
and  engineer  is  that  under  the  laws  of  Ohio  a  fireman  must  be  licensed  to 
run  a  fire  room,  and  this  operates  largely  to  make  him  independent  of  the 
engineer  in  charge,  so  that  criticism  or  complaint  of  the  firing  which  is  always 
in  large  measure  the  fault  responsible  for  smoke  nuisance,  is  withheld  for 
fear  of  loss  of  the  fireman  in  question. 

At  present  the  returns  from  the  city  expenditure  ($8,400.00  annually  in 
salaries)  for  smoke  abatement  are  negligible. 


90  Hospital  and  Health  Survey 


RECOMMEND  A  TIONS 

It  is  recommended  that: 

A  competent  engineer  familiar  with  the  technical  phases  of  cause  and  prevention  of 
smoke  nuisance,  and  with  the  harmful  results  to  property  and  life  from  such  other  kinds 
of  air  pollution  from  combustion,  refining,  smelting  and  other  industrial  processes  as 
are  common  in  Cleveland,  be  employed  as  Commissioner  of  Smoke  Prevention,  and  be 
paid  a  salary  commensurate  with  his  responsibility  (not  less  than  $6,000),  and  that  he 
be  provided  with  a  budget  which  will  permit  him  to  employ  through  civil  service  com- 
petent inspectors  (four  would  be  sufficient). 

The  Chamber  of  Commerce  resume  its  activities  in  the  public  interest  by  developing 
among  its  members  an  intelligent  activity  for  cleanliness  of  the  air  of  Cleveland,  by  aiding 
and  encouraging  prosecution  of  violators,  by  publishing  technical  bulletins  giving  modern 
standard  methods  of  mechanical  stoking  and  hand  firing,  by  serving  its  own  members 
through  an  inspection  service  which  will  prevent  any  of  its  members  from  coming  under 
criticism  by  the  city  inspectors. 

The  Cleveland  Betterment  Council  take  an  active  part  in  obtaining  proof  of  the 
damage  done  by  air  pollution  to  the  health  of  people  of  the  city,  through  regional  studies 
of  soot  fall,  etc.,  and  by  analysis  of  the  distribution  of  sickness  and  death,  in  cooperation 
with  the  Division  of  Health  and  the  public  nursing  agencies. 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing 

X.     Hospitals  and  Dispensaries. 

XI.     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 


The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 


THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Public   Health   Services 
Private   Health   Agencies 


Part  Two 


Cleveland     Hospital     and 
Health     Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -   Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following : 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary} 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director 

and  the  following  collaborators: 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  1$.  A.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  .  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

Page 
I.     Introduction _.__ 103 

II.     Public  Health  Services. 

Division  of  Health — 

Administration 110 

Appointments _ 112 

Appropriations 113 

Administrative  Districts _ ;..  114 

Bureaus — 

Communicable  Disease 122 

District  Physicians 138 

Tuberculosis 142 

Child  Hygiene 143 

Sanitation.. _ 144 

Food  and  Dairy  Inspection _ 148 

Milk  Control...... 150 

Laboratories , _ 155 

Patent  Medicines. 161 

Vital  Statistics '. 165 

New  Activities  Proposed — 

Institutional  Inspection 173 

Industrial  Hygiene 185 

Medical  Examination  for  City  Employes 185 

Public  Health  Education , __ 186 

Control  of  Drug  Addicts 189 

Health  Centers 190 

Coroner  Service 191 

III.     Private  Health  Agencies. 

Anti-Tuberculosis  League 193 

Visiting  Nurse  Association.. 193 

Day  Nursery  and  Free  Kindergarten  Association 193 

Hospital  Council 193 

Society  for  the  Blind  and  a  Program  for  the  Prevention  of 
Blindness. 193 

Associated  Charities 196 


TABLE  OF  CONTENTS— Continued 

Association  for  the  Crippled  and  Disabled  and  a  Program 
for  the  Care  of  Cripples. 197 

Proposed  Agencies  and  Programs  for — 

Prevention  and  Relief  of  Heart  Disease 213 

Prevention  and  Cure  of  Cancer ..^221 

IV.     Summary  of  Recommendations __.  226 

Appendix : 

Tables 231 


Health  Services 

By  Haven  Emerson,  M.  D. 
INTRODUCTORY 

"Public  health  is  the  science  and  art  of  preventing  disease,  prolonging 
life,  and  promoting  physical  health  and  efficiency  through  organized  com- 
munity efforts  for  the  sanitation  of  the  environment,  the  control  of  commun- 
ity infections,  the  education  of  the  individual  in  principles  of  personal  hygiene, 
the  organization  of  medical  and  nursing  service  for  the  early  diagnosis  and 
preventive  treatment  of  disease,  and  the  development  of  the  social  machinery 
which  will  insure  to  every  individual  in  the  community  a  standard  of  living 
adequate  for  the  maintenance  of  health." — C.-E.  A.  Winslow. 

PUBLIC  Health  Organization  in  the  majority  of  the  cities  of  the  United 
States  is  more  a  vision  than  a  reality,  a  hope  of  a  few  rather  than  a  living, 
growing,  democratic  function  of  civil  government  and  private  endeavor. 
Cleveland  has  gone  further  than  any  city  in  the  country  in  the  marshaling 
of  its  voluntary  community  resources,  both  financial  and  organization  for 
social  service.  It  has  created  the  spirit  of  Universal  support  for  those  activi- 
ties which  are  indispensable  to  human  progress,  and  there  has  been  capital- 
ized in  Cleveland,  as  nowhere  else,  the  conception  that  central  direction, 
study,  control  and  support  are  as  necessary  in  private  agencies  created  for 
the  prevention  and  remedy  of  the  evils  resulting  from  social  neglect  as  they 
are  in  private  business  or  in  the  functions  of  civil  government.  We  have  in 
Cleveland  the  legal  authority,  the  administrative  skeleton  for  a  public  health 
service  capable  of  including  all  the  functions  accepted  as  necessary  or  desir- 
able in  the  interest  of  health  conservation,  for  the  detection  or  arrest  of  in- 
cipient disease,  and  for  education  in  the  principles  and  practice  of  health 
development  and  protection.  What  we  see  in  action  is  but  a  meager  struc- 
ture, starved  by  scanty  appropriations,  occasionally  hampered  by  party 
politics,  only  partially  serving  some  of  the  elementary  functions,  and  in- 
capable of  undertaking  others  because  of  lack  of  heads  and  hands  to  plan 
and  carry  out  the  work. 

Supplementing  the  public  health  service  of  the  city  and  serving  many  of 
the  functions  already  assumed  by  the  public  authorities  in  many  other  places 
here  and  abroad  we  find  the  private  agencies  working  under  a  community 
budget,  receiving  support  by  a  voluntary  self-taxation  of  the  same  people 
who  pay  the  legal  compulsory  taxes  of  the  city.  Roughly  speaking,  about 
twice  as  much  money  is  raised  for  the  services  included  under  health  pres- 
ervation to  be  spent  by  private  agencies  annually  in  Cleveland  as  is  appro- 
priated by  the  civil  government  for  this  group  of  functions.  We  have,  as  it 
were,  a  democracy  within  a  democracy,  an  administrator  selected  by  agents 
serving  under  unofficial  direction,  countless  human  needs,  exercising  many 
of  the  functions  of  Chief  Executive  of  the  city,  as  well  as  an  elected  Mayor. 

The  Mayor  of  the  city  has  his  directors  of  departments,  his  technical 
advisors,  his  commissioners. 


104  Hospital  and  Health  Survey 

The  Director  of  the  Welfare  Federation  lacks  any  adequate  permanent 
specialist  in  the  field  of  health  to  advise  him  as  to  the  relative  necessities  and 
probable  results  in  preventive  medical  efforts  of  private  agencies. 

On  the  part  of  the  city  we  have  a  good  plan  for  a  machine,  but  lacking 
certain  essential  parts  and  without  the  power  to  produce  results. 

In  the  Welfare  Federation  there  is  vision,  imagination,  insight  into  the 
needs  and  sufficient  funds  to  supplement  the  public  service  for  health,  but 
without  a  trained  officer,  a  professional  student  or  administrator  of  health 
and  without  a  plan  for  its  own  future  in  this  field. 

In  order  to  make  the  demonstration  of  voluntary  community  organiza- 
tion clear  and  brilliant  Cleveland  owes  it  to  itself  and  to  the  other  great 
municipalities  of  the  country  to  assemble  within  one  local  public  health 
association  all  the  agencies  which  in  innumerable  ways  apply  the  knowledge 
of  modern  science  to  develop  health,  to  prolong  life,  to  prevent  disease,  to 
secure  in  physical  and  mental  happiness  all  we  know  normal  child  and  man 
are  capable  of. 

It  is  recommended:  That  there  be  created  a  Cleveland  Public  Health 
Association,  which  shall  include  in  its  membership  members  of  all  medical 
and  social  agencies  which  contribute  to  public  health  protection,  and  the 
governing  board  of  which  shall  be  composed  of  officially  designated  repre- 
sentatives of  each  component  agency  or  group  of  agencies. 

That  there  be  created  in  the  Welfare  Federation  the  position  of  Secretary 
for  Health,  and  that  this  position  be  filled  by  one  who  has  had  professional 
training  or  experience  in  public  health  work,  preferably  a  doctor  of  public 
health  or  a  physician,  and  that  the  functions  of  such  a  secretary  be  to  advise 
the  Director  and  through  him  the  Board  of  Directors  in  all  plans,  expendi- 
tures, policies  and  undertakings  of  the  Federation  in  the  field  of  health  and 
preventive  medicine,  to  make  studies  of  the  results  of  public  and  private 
efforts  in  this  field,  to  plan  and  carry  out  demonstrations  of  health  services 
which  it  may  be  desirable  to  establish  permanently  under  public  or  private 
auspices,  to  cooperate  with  and  in  every  way  to  assist  and  supplement  the 
service  provided  by  the  Division  of  Health  of  the  city. 

It  is  believed  that  unless  the  above  two  recommendations  are  substan- 
tially met,  in  spirit  if  not  in  the  precise  form  indicated,  a  large  part  of  the 
value  of  the  present  critical  inspection  and  analysis  of  Cleveland's  hospital 
and  health  resources  will  be  lost  and  the  public  interest  aroused  in  the  course 
of  the  very  broad  contact  with  many  groups  of  citizens  and  officers  of  the 
city  government  will  be  dissipated  before  action  is  taken. 

In  order  to  picture  more  definitely  than  we  find  it  understood  by  many 
interested  citizens  of  Cleveland,  the  history,  evolution  and  present  functions 
of  the  Welfare  Federation,  the  following  brief  statement  is  included  through 
the  courtesy  of  the  Director: 

"The  Welfare  Federation  is  an  outgrowth  of  the  community  teamwork  evidenced 
for  many  years  in  Cleveland. 


Public  Health  Services  105 


In  November,  1903,  the  Federation  for  Jewish  Charities  was  incorporated  to  collect 
and  apportion  contributions  for  the  maintenance  of  all  Jewish  charities,  the  promotion 
of  education,  science  and  art,  and  the  interests  of  members  of  the  Jewish  faith  and  of 
humanity  in  general. 

The  idea  of  federating  all  local  civic  and  philanthropic  work  originated  with  the 
Chamber  of  Commerce.  Mr.  Martin  A.  Marks,  interested  in  the  Jewish  Federation  and 
Chairman  of  the  Chamber  of  Commerce  Endorsement  Committee,  with  the  members  of 
that  committee,  visualized  the  strategic  advantage  of  conducting  an  attack  on  Cleveland's 
social  problems  from  the  vantage  point  of  the  "Allied  Council"  principle.  This  step 
followed  several  years'  work  of  the  Endorsement  Committee,  through  which  it  carefully 
worked  out  standards  and  practices  which  should  govern  the  organization  and  adminis- 
tration of  a  philanthropic  agency. 

The  Federation  for  Charity  and  Philanthropy,  as  the  organization  was  originally 
named,  was  formed  in  1913  to  aid  the  agencies  in  the  most  crucial  part  of  their  work — 
campaign-planning  and  money  raising;  to  save  them  from  going  twice  over  the  same 
ground,  and  to  give  each  agency  and  Clevelanders  in  general  a  view  of  the  city's  social 
field  and  problems  as  a  whole. 

By  1917  Cleveland  had  largely  lost  its  small-town  view  of  merely  localized  institu- 
tions to  be  cared  for.  It  had  seen  how  the  work  of  the  agencies  and  the  Federation  were 
related  and  how  they  must  be  coordinated  if  progress  for  the  city  were  to  be  made  without 
lost  motion  or  waste  energy.  Recognition  of  this  broadened  vision  was  evidenced  by 
an  enlarged  understanding  of  the  social  service  field  and  by  increased  and  popularized 
subscription  of  funds  for  social  service  work. 

During  this  time  the  Welfare  Council,  a  voluntary  combination  of  social  agencies 
and  civic  bodies,  with  no  budget  or  executive  staff,  had  been  formed  to  counsel  and  co- 
operate with  the  newly  created  Department  of  Public  Welfare,  as  well  as  to  promote  social 
welfare  measures  and  practices  among  private  philanthropic  organizations. 

The  merger  of  the  Federation  for  Charity  and  Philanthropy  and  the  Welfare  Council 
into  the  Welfare  Federation  of  Cleveland,  in  1917,  was  a  recognition  by  all  concerned 
that  the  functions  of  the  two  belonged  together.  Counsel  and  cooperation  between  public 
and  private  agencies  and  democratic  representation  of  the  social  service  bodies  were  thus 
secured  for  the  benefit  of  the  Welfare  Federation  and  the  good  of  the  city  when  each  mem- 
ber agency  of  the  old  Welfare  Council  was  accorded  representation  by  two  delegates  on 
the  General  Board  of  the  new  organization. 

This  body,  called  the  General  Board,  is  composed  of  two  delegates  from  each  member 
agency  of  the  Federation.  It  hears  and  discusses  policies  and  plans  for  new  movements, 
investigates  problems,  recommends  action  and  elects  the  active  Board  of  Trustees. 

The  Welfare  Federation  office  became  the  focal  center  for  cooperation  and  planning 
among  the  social  service  agencies.  It  is  the  larger  self  of  its  constituent  organizations 
and  serves  constituent  agencies  and  the  public  along  two  general  lines  of  activity: 

First:         Budget-making  and  money  raising. 

Second:    Social  planning,  problem  study  and  education. 

Under  the  impulse  of  the  unifying  motive  growing  out  of  the  war,  Cleveland,  in 
common  with  many  cities,  built  up  a  very  strong  organization  which,  through  united 


106  Hospital  and  Health  Survey 

effort,  gathered  money  for  the  various  purposes  connected  with  the  war.  This  organiza- 
tion succeeded  in  securing  more  than  one-third  of  all  the  population  as  subscribers  and 
generous  over-subscription  on  each  effort  and,  greatest  of  all,  these  experiences  revealed 
to  the  community  itself  a  fuller  measure  of  satisfaction  and  achievement  in  cooperative 
effort  than  the  city  had  ever  known  before.  All  distinctions  of  creed,  faith  or  political 
affiliation  were  forgotten  in  behalf  of  common  ideals  and  a  great  collective  purpose. 

Cleveland's  habit  of  working  together  through  its  federations  and  in  other  civic  ways, 
made  it  quite .  natural  that  it  should  preserve  this  effective  piece  of  machinery  created 
during  the  war.  Accordingly  the  war  organization  was  continued  under  the  name  of 
the  Community  Fund,  and  in  the  fall  of  1919  a  campaign  was  conducted  to  take  care  of 
the  current  needs  of  all  the  social  service  agencies  and  to  raise  Cleveland's  quota  for  un- 
finished war  needs  and  for  national  and  international  organizations  having  a  claim  on 
the  city's  cooperation. 

A  broad  campaign  of  education  and  publicity,  conducted  through  the  press,  the 
movies,  the  pulpit  and  lecture  platform,  window  exhibits,  parades  and  other  graphic  means 
of  publicity,  preceded  the  campaign.  The  number  of  subscribers  usually  contributing 
to  peace-time  enterprises  was  about  twenty  thousand.  This  campaign  enrolled  160,000 
givers,  again  more  than  reaching  the  goal,  which  was  $3,425,000,  the  amount  subscribed 
being  $4,015,000, 

For  nearly  twenty  years  Cleveland  has  been  studying  its  social  service  agencies.  In 
turn  it  developed  endorsing  work,  the  Jewish  Federation,  the  Welfare  Council,  the  Welfare 
Federation,  and  finally  the  Community  Fund.  While  this  development  had  made  much 
progress  in  the  way  of  budget  studies  and  in  the  planning  of  work,  each  year's  experience 
has  shown  the  need  for  more  definite  knowledge  and  for  more  intensive  effort  in  the  crea- 
tion of  standards.*  The  city  feels  a  responsibility  for  meeting  the  great  future  which  is 
before  it,  with  as  much  foresight  and  vision  as  is  humanly  possible  for  it  to  apply  to  these 
problems." 

CHARTER  PROVISIONS 

The  charter  of  the  city  of  Cleveland,  approved  July  1,  1913,  in  section  69, 
provides  for  the  election  of  a  Mayor  every  two  years.  The  City  Council, 
now  consisting  of  26  members,  one  councilman  from  each  ward,  is  elected  at 
the  same  time.  In  the  council  is  vested  the  legislative  power  of  the  city, 
except  as  reserved  to  the  people  by  the  charter.  These  are  the  only  elective 
city  officials  provided  under  the  charter. 

Section  78  of  the  charter  provides  for  administrative  functions  to  be 
carried  out  under  several  departments,  the  directors  of  which  form  the  May- 
or's cabinet — Law,  Public  Service,  Public  Welfare,  Public  Safety,  Finance, 
Public  Utilities,  Parks  and  Public  Property. 

Section  82  of  the  charter  provides  that  the  Mayor  and  directors  of  the 
various  departments  shall  constitute  the  Board  of  Control.  No  contracts 
involving  an  expenditure  in  excess  of  $1,000  can  be  awarded  except  on  the 

*Plans  for  a  hospital  and  health  survey  began  here  several  years  ago.  A  tentative  plan  was  then 
drawn  up  and  considered  by  the  Cleveland  Foundation.  This  was  the  beginning  of  agitation  for  a  sur- 
vey. The  thing  that  brought  it  to  the  forefront  again  last  year  was  the  number  of  hospital  projects  under 
consideration.  As  the  result  of  a  conference  in  Lakeside  Hospital,  the  Community  Fund  wrote  the  Presi- 
dent of  the  Welfare  Federation  about  it  and  he  called  a  meeting  of  interested  hospital  and  health  workers 
at  the  time  and  out  of  this  developed  the  Hospital  and  Health  Survey  under  the  auspices  of  the  Cleveland 
Hospital  Council. 


Public  Health  Services 


107 


approval  of  the  Board  of  Control  (Section  124).  Section  189  gives  the  Board 
of  Control  authority  to  fix  the  number  and  salaries  or  compensation  of  all 
the  officials  and  employes  except  the  directors  of  the  departments,  members 
of  the  City  Council  and  its  employes,  members  of  the  Division,  of  Police  and 
Fire  under  the  immediate  control  of  the  chiefs  thereof,  and  of t  the  members 
of  boards  or  commissions  in  the  unclassified  service  of  the  city. 

Section  41  states  that  the  fiscal  year  begins  on  the  first  day  of  January. 
On  or  before  the  15th  day  of  November  in  each  year  the  Mayor  prepares  an 
estimate  of  the  expense  of  conducting  the  affairs  of  the  city  for  the  following 
year.  This  estimate  is  compiled  from  detailed  information  obtained  from 
the  various  departments  on  uniform  blanks  prepared  by  the  Director  of 


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108  Hospital  and  Health  Survey 

Finance.  This  is  submitted  to  the  council,  which,  in  accordance  with  Sec- 
tion 42,  prepares  an  appropriation  ordinance,  using  the  Mayor's  estimate  as 
.a  basis.  Provisions  are  made  for  public  hearings  upon  the  appropriation 
ordinance  before  a  committee  of  the  council  or  before  the  entire  council 
sitting  in  committee  as  a  whole.  These  proceedings  are  public  and  are  pub- 
lished. 

Section  83  provides  that  the  director  of  a  department,  with  the  approval 
of  the  MayOr,  may  appoint  a  board  composed  of  citizens  qualified  to  act  in 
an  advisory  capacity  to  the  commissioner  in  any  division  under  his  super- 
vision. 

DEPARTMENT  OF  PUBLIC  WELFARE 

A  glance  at  the  organization  chart  of  the  city  government  (Figure  I) 
will  make  it  plain  that,  with  the  exception  of  the  health  functions  (educa- 
tional, protective  and  constructive)  which  are  served  by  the  Board  of  Edu- 
cation, all  the  public  health  services  of  the  city  of  Cleveland  fall  within  the 
Department  of  Public  Welfare.  Sections  81,  97,  98  and  99  of  the  charter 
concern  us  particularly  here. 

Section  81 

The  Department  of  Public  Welfare  is  the  one  to  which  is  entrusted  the 
administration  of  the  public  health  activities  in  the  city. 

General  Powers  and  Duties.     Section  97 

The  Director  of  Public  Welfare  shall  manage  and  control  all  charitable, 
correctional  and  reformatory  institutions  and  agencies  belonging  to  the  city; 
the  use  of  all  recreational  facilities  of  the  city,  including  parks,  playgrounds, 
public  gymnasiums,  public  bath  houses,  bathing  beaches  and  social  centers  . 
He  shall  have  charge  of  the  inspection  and  supervision  of  all  public  amuse- 
ments and  entertainments.  He  shall  enforce  all  laws,  ordinances  and  regula- 
tions relative  to  the  preservation  and  promotion  of  the  public  health,  the 
prevention  and  restriction  of  disease,  the  prevention,  abatement  and  sup- 
pression of  nuisances,  and  the  sanitary  inspection  and  supervision  of  the 
production,  transportation,  storage  and  sale  of  foods  and  food-stuffs.  He 
shall  cause  a  complete  and  accurate  system  of  vital  statistics  to  be  kept. 
In  time  of  epidemic  he  may  enforce  such  quarantine  and  isolation  regulations 
as  are  appropriate  to  the  emergency.  He  shall  have  the  supervision  of  the 
free  employment  office.  The  Commissioner  of  Charities  and  Corrections 
shall  be  the  Deputy  Director  of  Public  Welfare. 

Publicity  and  Research.     Section  98 

The  Commissioner  of  Publicity  and  Research  shall  provide  for  the  study 
of  and  research  into  causes  of  poverty,  delinquency,  crime,  disease  and  other 
similar  problems  in  the  community  and  shall  by  means  of  lectures,  exhibits 
and  in  other  proper  ways  promote  the  education  and  understanding  of  the 
community  in  those  matters  which  concern  the  public  health  and  welfare. 


Public  Health  Services  109 

Health  Commissioner.     Section  99 

The  Commissioner  of  the  Division  of  Health  shall  be  the  health  officer  of 
the  city,  and  shall,  under  the  direction  and  control  of  the  Director  of  Public 
Welfare,  enforce  all  ordinances  and  laws  relating  to  health,  and  shall  per- 
form all  duties  and  have  all  the  powers  provided  by  general  law  relative  to 
the  public  health  to  be  exercised  in  municipalities  by  health  officers;  pro- 
vided that  regulations  affecting  the  public  health,  additional  to  those  estab- 
lished by  general  law,  and  for  the  violation  of  which  penalties  are  imposed, 
shall  be  enacted  by  the  council  and  enforced  as  provided  herein. 


Public   Health    Services* 

THE  divisions  of  the  Department  of  Public  Welfare,  as,  outlined  in  the 
charter,  are:  Health,  Charities  and  Corrections,  Recreation,  Research 
and  Publicity  and  Employment.  The  Division  of  Recreation  has  been 
transferred  from  the  Department  of  Public  Welfare  to  the  Department  of 
Public  Service.  The  Division  of  Housing  has  been  transferred  from  the 
Department  of  Public  Safety  to  that  of  Public  Welfare.  The  Divisions  now 
functioning  are  those  of  Health,  Charities  and  Correction,  Employment, 
and  Housing. 

There  is  no  Commissioner  of  Research  and  Publicity,  although  a  brief 
experience  with  the  service  of  the  Division  of  Health  shows  clearly  the  sad 
lack  of  the  functions  which  such  a  Commissioner  might  have  been  supposed 
to  fill.  Inquiry  at  the  City  Hall  as  to  why  this  important  charter  position 
was  left  vacant  elicited  the  reply  that  such  a  service  would  only  create 
jealousy  among  the  departments  and  commissioners  because  of  the  cer- 
tainty that  the  "advertisement"  would  always  exploit  one  at  the  expense  of 
the  others.  There  seemed  to  be  no  conception  of  the  idea  that  was  obviously 
in  the  minds  of  the  charter  framers  that  a  city  government  needs  to  test 
administrative,  social  and  health  measures  and  must,  in  honesty  to  its  citi- 
zens, use  systematic  educational  publicity  to  interpret  its  work,  its  needs, 
its  difficulties'to  the  people,  and  to  have  an  organized  service  free  from  com- 
mercial pressure  or  the  warp  of  special  interests. 

With  the  right  man  in  such  a  place  the  community  would  double  its  return 
on  its  present  investment  in  its  Department  of  Welfare.  The  health  interests 
of  the  city  should  demand  that  the  position  be  filled. 

Among  the  obvious  and  desirable  services  to  be  rendered  by  educational 
publicity  for  the  Division  of  Health  are : 

(a)  Advertising  the  services  of  nurses,  clinics,  dispensaries,  health 
centers  and  hospitals. 

(b)  Gaining  the  cooperation  of  special  groups,  as  tenement  dwellers, 
restaurant  proprietors  and  storekeepers,  so  that  the  work  of  inspection  may- 
be made  easier  and  more  effective. 

(c)  Gaining  the  support  of  voters  for  legislative  programs  on  public 
health  and  sanitation. 

(d)  Developing  a  community  sensitiveness  and  conscience  in  matters 
affecting  the  sanitation  of  environment  and  the  maintenance  of  personal 
health. 

There  is  no  Board  of  Health  and  no  permanent  advisory  commission  or 
board  upon  whom  the  Commissioner  of  Health  relies  for  consideration  of 
policies  and  programs,  although  Section  83  provides  for  such. 

*In  the  preparation  of  the  following  description  of  the  powers,  functions  and  accomplishments  of  the 
Division  of  Health  the  Survey  has  received,  with  the  consent  and  approval  of  the  Commissioner  of  Health, 
Dr.  H.  L.  Rockwood,  valuable  original  data  from  the  unpublished  records  of  the  Division,  collected  and 
written  out  for  the  purposes  of  this  publication  by  Dr.  G.  W.  Moorehouse.  Chief  of  the  Bureau  of  Com- 
municable Disease,  whose  services  as  contributor  to  the  Survey  report  have  been  of  much  value. 


Public  Health  Services  111 

The  Director  of  the  Department  of  Public  Welfare  is  appointed  by  the 
Mayor.  The  Commissioner  of  Health  is  supposed  to  be  appointed  and 
may  be  removed  by  the  Director  in  conformity  with  the  civil  service  pro- 
vision of  the  charter  (Section  81).  As  a  matter  of  fact  the  selection  is  a 
personal  one  and  must  in  practice  suit  the  Mayor.  Health  Commissioners 
are  not  selected  on  a  civil  service  basis,  although  the  present  commissioner 
could  easily  qualify  in  any  impartial  examination.  The  commissioner  is 
supposed  to  appoint  all  officers  and  employes  of  the  division,  but  as  a  matter 
of  fact  he  has  to  accept,  in  major  official,  as  in  the  humble  positions  of  inspec- 
tor or  clerk,  those  sent  by  the  office  of  the  Mayor  or  by  other  city  officials 
with  the  Mayor's  sanction. 

Political  interference  with  personnel  in  a  service  requiring  so  much  tech- 
nical training,  depending  as  it  does  upon  carefully  coordinated  work  of 
the  bureaus  and  dealing  with  all  the  intimacies  of  disease  detection  and  con- 
trol and  the  conditions  of  living  of  individuals,  is  certainly  inimical  to  the 
best  public  interests.  Just  prior  to  elections  and  at  other  strategic  moments 
the  weight  of  political  pressure  by  correspondence  and  personal  notice  is 
occasionally  brought  to  bear  upon  the  personnel  of  the  division.  This  is  an 
intolerable  abuse  of  party  politics. 

The  Commissioner  of  Health  is  the  executive  officer  of  the  division.  His 
duties  are  to  direct,  control  and  supervise  the  work  of  the  division.  For  this 
he  receives  a  salary  of  $1,700.  He  is  at  the  same  time  Medical  Director  of 
the  Tuberculosis  Sanitorium  at  Warrensville,  for  which  he  receives  $3,300  a 
year.  The  latter  position  can  be  filled  adequately  by  a  part-time  physician 
if  he  has  the  knowledge  and  experience  possessed  by  the  present  commissioner. 
The  position  of  Chief  Executive  of  the  Division  of  Health  cannot  possibly  be 
filled  by  a  part-time  officer.  Nothing  less  than  full  time,  one  might  say  over- 
time and  all  the  time,  can  meet  the  needs  of  the  situation  with  the  insufficient 
staff  and  program  as  at  present  provided  for  the  Health  Division. 

Except  on  Sundays  and  holidays  the  office  of  the  Division  of  Health  is 
open  from  8:30  a.  m.  to  4:30  p.  m.  with  its  full  clerical  force.  At  noon  the 
members  of  the  office  staff  have  one  hour  off  for  lunch.  From  4:30  to  7:30 
p.  m.  on  week  days  and  from  9  a.  m.  to  12  noon  on  Sundays  and  holidays,  a 
desk  officer  is  present  to  receive  calls  for  district  physicians,  reports  of  com- 
municable diseases,  and  to  make  out  burial  permits.  In  epidemic  periods 
longer  hours  may  be  arranged. 

Supplies,  maintenance,  equipment  and  repairs  needed  by  the  Division  of 
Health  are  secured  by  requisition  and  the  system  of  checks  and  revisions 
appears  adequate  to  protect  the  city  in  emergency,  as  well  as  in  routine 
orders.  The  burden  of  the  system  falls  upon  the  commissioner,  who  is  really 
the  bookkeeper  of  the  Division.  The  divisional  store  room  serves  a  useful 
purpose  for  the  stock  of  standard  supplies.  An  annual  inventory,  with  state- 
ment of  depreciation,  is  taken  as  of  December  31st  for  the  information  and 
record  of  the  Director  of  Public  Welfare  and  the  Commissioner  of  Health. 


112  Hospital  and  Health  Survey 

There  are,  in  addition  to  the  Bureau  of  Administration,  which  consists  of 
the  commissioner  and  two  clerical  assistants,  the  following  bureaus: 

Communicable  Disease 

Tuberculosis, 

Child  Hygiene, 

Sanitation, 

Food  and  Dairy  Inspection, 

Laboratory, 

Vital  Statistics. 

Under  the  previous  Commissioner  of  Health  a  valuable  publicity  service 
by  a  monthly  educational  leaflet  and  a  question  and  answer  service  in  the 
newspapers,  was  provided  by  private  funds.  Budgetary  requests  for  public 
health  education  have  been  struck  out  of  the  appropriation  ordinances  each 
year. 

The  service  of  the  Bureau  of  Communicable  Diseases  for  venereal  disease 
control  is  dependent  upon  outside  support. 

The  Bureau  of  Child  Hygiene  does  not  include  prenatal  and  maternity 
services,  or  school  medical  inspection  for  parochial  schools. 

There  is  no  housing  or  institutional  inspection  service  provided,  although 
these  functions  might  be  served  by  an  expansion  of  the  bureaus  of  sanitation 
and  of  child  hygiene. 

There  is  no  service  for  industrial  hygiene. 

Appointments 

The  Civil  Service  Commission  states  that  the  Commissioner  of  Health 
and  all  employes  of  the  Division  of  Health  are  under  the  classified  civil  serv- 
ice and  in  the  class  known  as  competitors.  (See  Amendments  to  the  Char- 
ter, Sec.  131).  However,  examinations  for  physicians  and  nurses  have  never 
been  given,  and  the  commission,  after  investigation,  concludes  that  competi- 
tive examinations  for  these  positions  are  not  entirely  practical.  As  a  result 
of  this  decision  the  clerical  positions  in  the  Division  of  Health  and  those  of 
sanitary  officers  are  the  only  ones  for  which  examinations  have  been  given. 

When  a  vacancy  exists,  the  list  of  applicants  who  have  taken  the  examina- 
tion is  consulted  and  an  appointment  is  made  from  this  list.  Should  there 
be  no  such  list,  a  condition  which  often  occurs,  a  vacancy  may  be  filled 
temporarily,  but  such  appointee  must  take  the  examination  as  soon  -as  an 
opportunity  offers.  Should  the  applicant  fail  in  the  examination  and  there 
be  still  no  list  from  which  an  appointment  may  be  made,  the  applicant  may  be 
continued  in  the  position. 

Applications  for  the  position  of  field  nurse  must  pass  through  the  hands 
of  the  Central  Committee  on  Public  Health  Nurses,  a  private  organization, 
and  be  acted  upon  by  this  body.     This  committee  consists  of  a  lay  and  a  pro- 


Public  Health  Services  113 

fessional  representative  of  the  Visiting  Nurse  Association,  school  nurses  from 
the  Board  of  Education  and  field  nurses  of  the  Division  of  Health.  This 
procedure  is  in  no  way  provided  for  in  the  city  charter  or  by  ordinance.  It 
is  entirely  extra-legal.  The  same  end  would  be  attained  within  the  law  if 
the  Civil  Service  Commission  designated  the  Central  Nursing  Committee  as 
examiners  of  nurses  applying  for  positions  in  the  classified  service.  The 
recommendations  of  this  committee  are  needed  in  the  appointment  of  visit- 
ing and  school  nurses  as  well  as  the  field  nurses  of  the  Division  of  Health.  In 
this  way  an  excellent  type  of  nurse  for  these  positions  is  secured. 

There  is  no  probationary  period  for  employes  of  the  Division  of  Health 
and  there  are  no  formal  reports  on  efficiency.  There  is  no  physical  examina- 
tion given  for  physical  fitness  before  employment  and  none  are  provided 
thereafter.  Except  for  the  sanitary  police,  who  share  in  the  rights  of  the 
police  pension  fund,  no  employes  of  the  Division  of  Health  have  any  rights 
in  any  city  pension  fund.  All  sanitary  police  receive  a  complete  physical 
examination,  including  a  Wassermann  test. 

The  appropriation  for  the  Division  of  Health  for  1920  is: 

Bureaus 

General  Administration $  6 ,  650  of  which    $  5 ,  990  is  for  salaries. 

Communicable  Diseases 57,010  " 

Tuberculosis 79,368  " 

Child  Hygiene 80,304  " 

Sanitation 60,170  " 

Food  and  Dairy  Inspection 49 ,  994  " 

Laboratories _ 34,468  " 

Vital  Statistics 7 ,  029  " 


37,800 

« 

it           « 

74,670 

« 

M                U 

76 , 774 

« 

it           a 

51,857 

a 

«               (I 

48,436 

U 

It               (( 

31,409 

(i 

((               it 

7,029 

a 

U               M 

$374,993        $333,965 

or  a  total  appropriation  of  47c  per  capita  of  the  population'of^Cleveland  as 
of  January,  1920  (796,836). 

The  per  capita  cost  of  the  Division  of  Health  varied  between  10  and  13.6 
cents  per  capita  (usually  about  12^  cents)  from  1884  to  1898;  from  1899  to 
1901,  30  to  37  cents;  1902  about  60  cents,  the  high  years  1899-1902  being 
due  to  smallpox.  The  appropriations  for  smallpox  in  these  years  built  a 
smallpox  hospital  on  the  City  Hospital  grounds,  a  frame  building,  which  was 
later  renovated  for  advanced  cases  of  tuberculosis.  From  1903  to  1910  the 
expenditures  averaged  somewhat  more  than  20  cents  per  capita.  In  1909 
smallpox  again  threatened  to  become  serious  and  the  health  office  received 
an  appropriation  of  $50,000.  $12,000  of  this  was  used  to  combat  the  disease 
and  the  remainder  to  complete  the  contagious  disease  building  at  the  City 
Hospital.     In  1913-1919  the  per  capita  cost  rose  from  38  to  41  cents. 

The  per  capita  cost  in  1915  was  35.7  cents.  When  it  is  recalled  that  a  dol- 
lar in  1920  will  buy  in  terms  of  service  and  supplies  little  more  than  half 
what  it  would  in  1915,  the  absolute  increase  to  47  cents  per  capita  of  the 


114  Hospital  and  Health  Survey 

appropriation  really  means  a  decided  reduction  in  public  health  service  as 
compared  with  the  appropriations  before  the  war  which  were  even  then  less 
than  half  the  amount  spent  by  some  progressive  communities. 

The  city  of  Detroit  has  appropriated  for  the  current  year's  health  budget 
a  total  of  $709,570,  or  71.4  cents  per  capita.  This  appropriation  includes 
the  same  services  as  are  provided  for  in  Cleveland's  budget  above  specified 
with  the  exception  that  school  medical  inspection  for  all  the  schools  is  pro- 
vided for  within  the  health  department  in  Detroit.  If  this  deduction  is 
made  the  per  capita  allowance  for  functions  essentially  identical  with  those 
provided  for  in  the  Cleveland  Division  of  Health  will  cost  Detroit  60  cents 
per  capita. 

There  is  a  total  of  250  employes  provided  for,  of  whom 
37  are  physicians, 
45  are  from  other  professions  or  are  technicians,  veterinarians, 

bacteriologists,  chemists,  etc. 
85  are  nurses, 

31  are  sanitary  police  officers, 

40  are  clerical  assistants,  stenographers,  typists,  etc. 
12  are  laborers,  cleaners,  messengers,  etc. 

The  eight-hour  day  is  the  rule,  except  for  the  part-time  employes,  and  for 
the  district  physicians  who  are  on  call  day  and  night. 

One  day's  vacation  for  each  month  of  service  up  to  a  maximum  of  two 
weeks'  vacation  each  year  is  allowed.  Sick  leave  with  pay  up  to  two  weeks 
in  a  year  is  provided  for.  Organized  care,  medical  and  nursing,  for  sick 
employes  is  not  provided,  but  the  district  physicians  visit  sanitary  officers 
for  illness,  and  nurses  visit  nurses  reporting  ill. 

Keeping  track  of  the  payroll  and  absences  from  work  is  adequately  pro- 
vided for  in  the  commissioner's  office. 

Administrative  Districts 

There  are  districts  for  sanitary  inspection,  districts  for  the  city  (district) 
physicians,  and  so-called  Health  Center  districts,  none  of  which  coincide 
with  any  unit  for  which  complete  population  data  are  available.  If  it  is 
found  desirable  to  continue  the  use  of  the  three  sets  of  districts  as  at  present, 
they  should  be  so  outlined  as  to  include  multiples  of  the  census  tracts  or  sani- 
tary areas  for  which  population  data  can  readily  be  made  available.  As  it  is 
at  present  neither  the  Commissioner  of  Health  nor  his  officers  know  the 
population,  the  rates  of  births,  deaths  or  morbidity  for  the  areas  of  the  dif- 
ferent districts,  although  a  beginning  has  been  made  to  collect  and  tabulate 
information  according  to  Health  Center  districts.  These  are  shown  in  Fig. 
HI. 

It  is  recommended  that  the  city  government  and  private  agencies  operat- 
ing field  services  or  serving  community  needs  adopt  as  the  basis  for  all  ad- 
ministrative districts  the.  so-called  census  tracts,  or  as  they  are    called    in 


Fig.  II. 

Census  Tract  or  Sanitary  Area 


Public  Health  Services  115 

certain  cities,  sanitary  areas.  These  sanitary  areas,  of  which  there  are  131 
officially  designated  and  used  by  the  Census  Bureau  for  the  collection  of 
population  data,  are  sufficiently  small  to  make  it  possible  by  assembling  such 
areas  to  outline  administrative  districts  suitable  for  all  varieties  of  medical, 
social  and  public  administration  work  (see  map  of  city,  giving  these  sanitary 
areas,  Fig.  II.).  When  it  is  appreciated  that  all  the  important  data  which  are 
used  to  measure  the  results  of  health  work,  the  distribution  and  shifting  of 
population  and  the  results  of  all  varieties  of  social  effort  for  the  community, 
are  collected  and  made  available  through  the  Federal  Census  for  each  of  these 
small  districts,  the  value  of  operating  public  and  private  medico-social  utili- 
ties, according  to  districts  for  which  all  this  important  information  will  be 
easily  available  for  comparison  decade  by  decade,  can  readily  be  seen. 

The  administration  of  the  Division  of  Health  is  centralized,  the  main 
office  and  the  laboratories  being  at  the  City  Hall.  The  district  physicians 
receive  calls  through  the  City  Hall  and  through  the  police  stations  in  their 
district  and  at  night  at  their  homes.  The  work  of  the  Bureaus  of  Child 
Hygiene  and  Tuberculosis  is  done  largely  from  and  in  district  offices  called 
Health  Centers,  which  are  really  branch  offices  for  the  convenience  of  provid- 
ing diagnostic,  educational,  nursing  and  follow-up  care,  in  locations  easily 
accessible  to  the  homes  of  the  majority  to  be  served.  Detailed  description  of 
the  functions  and  administraton  of  these  centers  will  be  found  under  the 
chapters  and  Dispensaries,  Public  Health  Nursing  and  Child  Hygiene  (Parts 
X.,  IX.  and  III.) 

Although  the  use  of  these  district  centers  for  tuberculosis  and  infant  wel- 
fare work  was  an  innovation  in  the  administration  of  the  Cleveland  Division 
of  Health,  neither  the  principle  nor  the  methods  constitute  an  important  step 
in  health  administration  except  in  the  feature  of  having  the  nurses  from  the 
two  bureaus  serve  all  public  health  functions  in  their  districts  regardless  of 
the  bureau  to  which  they  are  credited  on  the  payroll.  Concerning  this  im- 
portant and  controversial  type  of  public  health  nursing  service,  detailed 
discussion  will  be  found  in  the  appropriate  chapter  on  public  health  nursing. 
(Part  IX.). 

For  the  work  of  the  Bureaus  of  Tuberculosis  and  Child  Hygiene  the  city 
is  divided  into  seven  districts  with  "Health  Centers."  These  are  housed  in 
dwellings,  apartments  or  ground  floor  store  rooms.  Historically  these  were 
originally  tuberculosis  dispensaries,  each  with  its  staff  of  a  doctor,  a  super- 
visor and  a  group  of  nurses.  At  present  each  has  in  addition  a  baby's 
prophylactic  dispensary  with  its  dispensary  physician,  five  have  offices  for 
a  district  physician,  and  three  have  dental  equipment.  The  nursing  service 
is  generalized.  There  are  eight  baby's  prophylactic  dispensaries,  in  addition 
to  the  seven  in  Health  Centers,  or  a  total  of  fifteen. 

A  portion  of  District  2  is  set  off  from  the  remainder  as  a  teaching  center 
for  Public  Health  Nursing,  under  the  direction  and  supervision  of  Western 
Reserve  University.  There  is  no  district  physician  or  tuberculosis  dispensary 
assigned  exclusively  to  this  territory,  a  baby's  dispensary  is  located  in  it, 
however.     The  nursing  service  for  this  territory,  containing  about  9%  of  the 


116  Hospital  and  Health  Survey 

city's  population,  is  given  by  the  staff  of  instructors  and  pupils  of  the  Uni- 
versity at  no  cost  to  the  city.  It  is  commonly  referred  to  as  "University 
District,"  or  District  8. 

Fig.  HI.  shows  the  location  of  the  offices  and  dispensaries  in  each  health 
district  which  provide  for  prevention  of  disease  or  for  treatment  of  the  sick. 
(The  area  omitted  at  the  east  end  of  District  6  does  not  contain  any  of  the 
facilities  considered.) 

Fig.  IV.  shows  for  each  health  district: 

1.  The  estimated  number  of  expectant  mothers  under  prenatal  care 
per  1,000  births. 

2.  The  birth  rate  per  1,000  population. 

3.  The  rate  of  still-births  per  1,000  registered  births. 

4  and  5.    The  death  rate  of  infants  under  one  month  and  under  one 
year  per  1,000  registered  births. 

6.  The  number  of  babies  reported  for  the  first  time  at  the  baby  stations 
per  1,000  children  under  two  years. 

All  these  figures  are  for  a  period  of  twelve  months  in  1919-20. 

Table  I.  in  the  appendix  gives  by  health  districts  for  the  year  1919-20 
important  information  concerning  births,  by  sex,  nativity  and  character  of 
professional  attendance  at  the  birth. 

Table  II.  gives  for  each  health  district  for  the  year  1919-20  an  analysis 
of  all  deaths  by  race,  under  one  year,  and  for  the  diseases  upon  which  the  so- 
called  sanitary  index  is  calculated. 

Conferences 

The  Commissioner  calls  an  advisory  committee  occasionally,  usually  in 
the  presence  of  emergencies.  The  Commissioner  has  obtained  valuable 
assistance  from  conference  with  a  committee  of  druggists  in  determining 
policies  and  action  in  the  control  of  sale  of  patent  medicines. 

The  Commissioner  holds  no  regular  conferences  with  the  chiefs  of  the 
bureaus  of  his  division.  There  have  been  a  few  conferences  held  by  the 
Commissioner  during  the  past  year  with  the  physicians  on  tuberculosis  clinic 
duty,  and  with  the  directors  and  supervisors  of  field  nurses  engaged  in  this 
work. 

There  are  weekly  meetings  held  by  the  Director  of  Public  Health  Nursing 
of  the  Division  which  all  the  nurses  are  expected  to  attend.  They  discuss 
their  work  and  occasionally  have  professional  matters  presented  to  them  by 
speakers  from  outside  the  division. 

Library 

There  is  no  library  or  collection  of  public  health  literature  or  reports  or 
professional  publications  kept  in  the  Division  of  Health.     The  Municipal 


Public  Health  Services 


117 


118 


Hospital  and  Health  Survey 


Public  Health  Services  119 

Reference  Library,  which  is  situated  on  the  fourth  floor  of  the  City  Hall, 
contains  considerable  public  health  literature,  however,  and  is  available  for 
reference. 

Legal  Action 

Each  bureau  of  the  Division  of  Health  from  which  prosecutions  originate 
handles  these  prosecutions  without  any  uniform  method  of  reference  to  the 
Commissioner.  The  number  of  convictions  or  the  failure  to  secure  convic- 
tions is  not  indicated  in  the  report  of  the  bureau  chief  to  the  Commissioner. 
All  legal  action  taken  as  a  result  of  the  activities  of  any  bureau  might  well  be 
handled  by  a  single  officer  or  through  a  centralized  service  in  the  Bureau  of 
Administration  rather  than  in  the  present  way. 

Sanitary  Code 

In  March,  1908,  a  sanitary  code  was  adopted  and  published  covering 
many  of  the  important  provisions  of  law  necessary  to  permit  control  of  nui- 
sances, of  communicable  diseases,  of  meats,  milk,  dairy  and  other  food 
products  and  food  stores,  of  housing,  of  disposal  of  the  dead,  ice,  public 
conveyances,  spitting,  barber  shops,  etc. 

Recently  a  revised  and  modern  sanitary  code  has  been  adopted  which 
gives  authority  and  defines  sanitary  standards  in  substantial  agreement  with 
modern  practice.  During  the  past  several  years  (since  1913)  there  has  been 
an  interval  since  the  former  code  became  inoperable  under  the  law  and  until 
the  recent  enactment  of  the  revised  code  there  has  been  great  and  at  times 
insuperable  difficulty  met  by  the  Division  of  Health  in  enforcing  the  essential 
requirements  for  sanitation  and  disease  control.  As  long  as  the  rules  and 
regulations  under  which  the  Division  of  Health  must  operate  and  which 
are  the  basis  for  its  legal  action  to  abate  nuisances,  require  reports  of  births 
or  registry  of  midwives,  or  to  control  the  persons  or  premises  where  com- 
municable disease  is  found,  are  passed  or  enacted  only  by  the  council  of  the 
city,  there  will  be  much  waste  of  time  and  effort  in  persuading  these  rela- 
tively uninformed  and  uninterested  laymen  of  the  essential  needs  for  good 
public  health  administration.  A  charter  change  should  be  made  which  would 
permit  of  the  writing  by  the  Commissioner  of  Health,  assisted,  by  an  advisory 
commission  of  physicians  and  sanitarians,  of  rules  and  regulations  dealing 
with  protection  of  public  health,  such  regulations  to  have  the  force  and 
effect  of  city  ordinances  as  do  those  now  enacted  by  the  council. 

Filing 

Each  Bureau  of  the  Division  of  Health  maintains  its  own  filing  system; 
that  of  the  Commissioner  and  those  of  communicable  disease,  tuberculosis 
and  vital  statistics  being  kept  at  the  central  office.  Each  health  center  has 
a  record  of  all  families  for  whom  work  has  been  done  by  the  nurses  and  a 
medical  history  with  nurse's  notes  of  those  patients  who  have  visited  the 
tuberculosis  dispensary. 


120 


Hospital  and  Health  Survey 


1917 — Death  Rate  per  1,000  Population.     Figures  based  on  population  as  estimated  by  the  Bureau 

of  Census  for  the  year  1917. 


NEW  ORLEANS 


DETROIT 


PITTSBURGH 


WASHINGTON 


TOLEDO 


NEW  HAVEN 


PHILADELPHIA 


BOSTON 


CINCINNATI 


BUFFALO 


LOUISVILLE 


DAYTON 


PROVIDENCE 


ROCHESTER 


SAN  FRANCISCO 


ST  LOUIS 


CHICAGO 


JERSEY  CITY 


COLUMBUS 


NEWARK 


NEW  YORK 


LOS  ANGELES 


DENVER 


MINNEAPOLIS 


19.9 


19.0 


J18.2 


Fig.  V. 


Public  Health  Services  121 

Morale 

In  spite  of  the  handicaps  indicated  in  the  brief  description  above  there  is 
evident,  particularly  among  the  physicians,  nurses,  inspectors  and  laboratory 
workers  of  the  Division  of  Health  a  spirit  of  devotion  and  enthusiasm,  a 
true  morale  which  speaks  well  for  the  unselfishness  in  the  leadership  and  direc- 
tion of  the  work.  Although  more  could  be  done  with  improved  organization 
and  additional  personnel  there  is  being  given  to  Cleveland  by  those  consti- 
tuting the  modest  force  of  the  Division  of  Health  a  quality  of  service  out  of 
proportion  to  the  remuneration  and  public  support  accorded  them. 

There  is  herewith  presented  in  Fig.  V.  in  graphic  form  the  death  rate  for 
each  of  25  cities  in  the  United  States  for  the  year  1917  from  the  figures  of 
the  Bureau  of  the  Census,  the  last  available. 

Cleveland  will  doubtless  wish  and  undertake  to  attain  a  higher  relative 
position.  No  municipality  wants  to  be  merely  in  the  middle  of  such  a  series. 
To  be  number  thirteen  when  there  are  twelve  better  places  to  fill  is  a  chal- 
lenge to  the  energy  and  capacity  of  the  city's  Division  of  Health. 


122  Hospital  and  Health  Survey 

The  Bureau  of  Communicable  Disease 

Authority  and  Scope 

ORDINANCE  No.  32846-B,  passed  by  the  council  July  13,  1914,  and 
amended  chiefly  with  respect  to  influenza  and  influenza-pneumonia, 
September  5,  1919,  provides:  that  there  be  created  in  the  Division  of 
Health  a  Bureau  of  Communicable  Disease.  The  function  of  the  bureau 
shall  be  to  prevent  the  transmission  of  communicable  diseases,  perform  disin- 
fection, establish  and  maintain  quarantine,  and  to  perform  such  other  duties 
as  shall  be  deemed  necessary  for  the  prevention  and  control  of  epidemics. 

The  Chief  of  the  Bureau  of  Communicable  Disease  shall  be  a  graduate  of 
medicine,  shall  act  as  the  medical  consultant  of  the  Division  of  Health,  and 
shall  direct  the  activities  of  the  bureau.  Under  the  direction  of  the  Com- 
missioner of  Health  the  work  of  the  Bureau  of  Communicable  Disease  is 
carried  on  by  the  following:  a  chief  physician  (Chief  of  the  Bureau),  seven 
senior  physicians  (district  physicians),  with  the  assistance  of  a  sergeant  and 
five  sanitary  officers,  nurses  and  typists.  The  Chief  of  the  Bureau  supervises 
the  activities  of  the  Division  of  Health  in  the  control  of  communicable  dis- 
ease, examines  for  diagnosis  suspected  cases  and  makes  personal  investiga- 
tion when  difficulty  arises  in  the  establishment  of  quarantine.  In  the  past 
smallpox  has  very  frequently  demanded  a  large  part  of  the  time  of  the  Chief 
of  the  Bureau.  In  epidemic  periods  he  has  commonly  investigated  all  cases 
of  cerebro-spinal  meningitis  or  infantile  paralysis  or  assigned  the  same  to 
others  for  investigation. 

The  revised  Sanitary  Code  gives  adequate  authority  for  the  control  of 
the  acute  communicable  disease  within  the  City  of  Cleveland  and  on  vessels 
arriving  in  the  harbor  of  the  city. 

There  is  no  subdivision  for  venereal  diseases,  but  one  is  under  considera- 
tion and  provision  is  made  for  such  a  division  in  the  budget  prepared  for  next 
year.  For  details  of  the  needs  and  suggested  organization  and  functions  of 
such  a  subdivision  of  venereal  diseases  see  the  report  on  venereal  disease, 
Part  V. 

The  control  of  communicable  diseases  in  animals  is  vested  at  present  in 
the  Bureau  of  Food  and  Dairy  Inspection,  because  there  are  veterinarians 
included  only  in  the  personnel  of  this  bureau.  It  would  be  in  the  interest  of 
good  organization  to  have  the  veterinary  work  in  connection  with  communi- 
cable diseases  as  well  as  the  care  and  treatment  of  human  rabies  included 
within  the  Bureau  of  Communicable  Diseases. 

It  is  probable  that,  with  the  expansion  of  the  scope  and  usefulness  of  the 
Division  of  Health,  preventable  diseases  of  occupation  or  industry,  prevent- 
able diseases  of  habit,  such  as  narcotic  addiction,  and  the  control  of  pre- 
ventable mental  diseases  will  all  be  included  together  with  tuberculosis  and 
venereal  disease,  under  a  Bureau  of  Preventable  Diseases,  each  large  sub- 
group being  dealt  with  in  a  special  subdivision.  All  the  group  diseases,  the 
communicable  in  man  and  animals,  as  well  as  the  non-communicable  which 


Public  Health  Services  123 

come  under  the  term  preventable,  require  the  study  of  experts  in  epidemi- 
ology and  the  constant  research  of  trained  technicians  in  the  laboratory 
sciences.  The  kind  of  high  grade  research  and  direction  needed  in  this  field 
can  be  obtained  or  justified  only  if  there  is  a  consolidation  of  the  services 
coming  under  a  bureau  dealing  with  all  preventable  diseases. 

Of  the  list  of  diseases  for  which  report  is  required  impetigo  contagiosa, 
pemphigus  neonatorum,  tinea  and  scabies,  might  be  omitted  without  any 
loss  of  service  to  the  public.  It  is  believed  that  there  should  be  enforcement, 
with  penalties  for  failure  to  report,  until  there  is  something  approaching  com- 
plete reporting  of  the  more  important  diseases.  No  additions  to  the  list  are 
suggested.  To  forbid  those  infested  with  scabies  or  afflicted  with  impetigo 
or  tinea  to  mingle  in  any  way  with  the  public  has  about  the  same  effect  as 
good  advice  given  in  doctors'  offices,  but  unless  there  is  an  attempt  to  enforce 
such  regulations  they  are  better  omitted  from  the  body  of  the  law. 

The  following  provision  of  the  Sanitary  Code  is  extreme  and  its  enforce- 
ment is  not  justified  without  liberal  qualifications.  It  is  often  disregarded 
and  should  be  modified.  "No  superintendent,  principal  or  teacher  of  any 
public,  parochial  or  private  school  or  other  institution,  nor  any  parent,  or 
other  person  shall  permit  any  child  having  any  communicable  disease  or  any 
child  living  in  a  family  where  such  a  disease  exists,  or  has  recently  existed, 
to  attend  school  until  the  Division  of  Health  shall  certify  in  writing  that 
danger  from  infection  has  been  removed  by  recovery,  removal  or  death  of 
the  patient,  and  disinfection  has  been  made  according  to  the  requirements  of 
the  Division  of  Health." 

Control  of  undertakers  by  license  and  regulations  governing  their  pro- 
cedure in  the  case  of  deaths  resulting  from  certain  communicable  diseases 
Would  be  better  than  requiring  the  presence  of  a  sanitary  officer  at  the  burial. 
Such  extreme  precaution  applied  to  bodies  after  death  is  out  of  proportion 
to  the  risk.  "Every  undertaker  receiving  notice  or  being  called  upon  to 
prepare  for  burial  the  body  of  any  person  who  has  died  from  smallpox,  scarlet 
fever,  diphtheria,  membranous  croup,  infantile  paralysis,  or  cerebro-spinal 
meningitis,  shall  within  twelve  hours  after  receiving  such  notice  or  call, 
notify  the  Division  of  Health  of  the  time  of  burial,  and  such  burial  shall  not 
take  place  without  the  presence  of  a  sanitary  officer."  It  is  not  the  corpse 
but  the  undetected,  the  early,  the  carrier  case  about  on  his  feet,  who  spreads 
disease. 

The  following  requirement  is  superfluous  if  the  casket  is  tight,  as  required 
in  another  section :  "No  undertaker  shall  use  any  vehicle  other  than  a  hearse 
for  conveying  the  body  of  any  person  who  died  from  any  of  the  following 
diseases:  Acute  Poliomyelitis  (infantile  paralysis),  Cerebrospinal  Menginitis, 
Asiatic  Cholera,  Diphtheria,  Influenza  or  Influenzal  Pneumonia,  Dysentery 
(Amoebic  or  Bacillary),  Plague,  Scarlet  Fever,  Smallpox,  Yellow  Fever." 

The  regulations  for  the  isolation  period  for  the  various  diseases  are  in 
process  of  revision  to  correspond  with  the  standards  recommended  by  the 
American   Public  Health  Association.     These  regulations  will  make  some 


124  Hospital  and  Health  Survey 

changes  in  procedure,  the  most  important  of  which  are :  placarding  solely  by 
the  sanitary  officers;  instruction,  the  granting  of  permits  and  the  lifting  of 
quarantine  solely  by  the  nurses  acting  as  quarantine  officers. 

Reporting  of  Communicable  Diseases 

Cleveland  physicians  have  for  many  years  been  furnished  stamped 
postal  cards  for  reporting  communicable  diseases  to  the  Division  of  Health, 
but  under  the  Griswold  Act  they  have  recently  received  books  of  franked 
cards  (with  stub)  for  this  purpose.  By  far  the  largest  number  of  physicians' 
cases  are  reported  by  telephone.  Before  quarantine  is  instituted  in  reported 
cases  of  smallpox  or  of  chickenpox  in  adults  (over  13)  the  case  is  investigated 
for  correctness  of  diagnosis  by  the  physician  of  the  Division  of  Health  acting 
in  the  capacity  of  diagnostician. 

The  following  cards  are  used  at,  or  turned  in  at  the  Communicable  Dis- 
ease desk: 

The  "telephone  ticLef'is  for  immediate  entry  of  all  reported  cases.  It 
provides  for  the  disease,  the  date  reported,  how  reported,  the  address  and 
name  of  patient,  the  physician  and  his  address,  the  officer  carding,  the  date 
carded  and  remarks. 

The  "quarantine  officer's  report"  provides  for  a  report  on  all  the  data 
mentioned  above  with  several  additional  items,  as:  date  of  onset,  names  of 
other  members  of  the  family  if  found  sick,  milk  supply,  library  books,  water 
supply,  number  of  children  and  adults  in  family,  number  attending  school, 
what  schools,  where  carded,  where  adults  are  employed,  the  number  of 
rooms  in  house,  etc. 

The  "street  file"  provides  for  the  name  of  the  disease,  the  case  number, 
the  address,  name  of  patient,  occupation  of  parents,  name  of  attending 
physician,  name  of  officer  who  imposes  quarantine  and  who  later  releases 
from  quarantine,  number  of  school  permits  granted,  removal  to  hospital. 
Dates :  of  report,  of  quarantine,  of  receipt  of  convalescent  slip,  of  commencing 
convalescence,  of  death,  of  release  from  quarantine  and  of  disinfection. 

The  "nurse's  card"  provides  for  a  report  of  essentially  the  same  facts 
as  those  asked  for  on  the  quarantine  officer's  report  card.  All  homes  quaran- 
tined for  diphtheria  and  scarlet  fever  are  visited  by  public  health  nurses  and 
this  card  is  made  out  for  each. 

The  "convalescent  ticket"  is  left  in  the  home  so  that  the  attending 
physician  may  give  the  Division  of  Health  the  date  of  beginning  convales- 
cence. 

The  "convalescent  card"  is  made  out  upon  the  receipt  of  the  convalescent 
ticket  and  filed  under  the  street  address. 

The  work  and  school  permits  are  given  to  adults  and  children  released 
from  quarantined  premises  during  quarantine  and  to  the  patient  and  others 
at  the  end  of  quarantine. 


Public  Health  Services  125 

The  report  of  the  sanitary  officer  of  various  types  of  work  performed: 
Disinfection,  attendance  upon  private  funerals,  spraying,  enforcing  quaran- 
tine, etc. 

The  record  of  eye  cases  received.  • 

The  cards  described  are  used  as  follows  in  the  quarantined  diseases: 
all  telephone  tickets  are  taken  by  the  sergeant  in  charge  of  sanitary  officers 
assigned  to  the  bureau  and  given  out  to  the  officers  for  placarding.  The 
name  of  the  officer  having  the  assignment  and  the  date  the  case  was  carded 
is  entered  upon  the  ticket.  The  officer  cards  the  house,  front  and  rear 
entrances,  or  if  an  apartment  or  hotel,  the  entrance  of  the  apartment,  tells 
the  family  the  precautions  to  be  used  in  keeping  quarantine,  grants  or 
withholds  work  permits  as  circumstances  require,  and  fills  out  the  quarantine 
officers'  report.  The  sanitary  officers  receive  their  work  at  8  a.  m.  at  the 
office.  They  call  in  from  their  districts  at  noon  and  again  at  4  p.  m.  for  work 
which  comes  in  later  in  the  day. 

In  District  No.  1  and  in  the  University  District  the  nurses  act  as  quaran- 
tine officers,  placard  houses,  give  permits  and  make  out  officers'  reports.  In 
all  districts  the  nurses  visit  all  cases  of  diphtheria  and  scarlet  fever  to  give 
instructions  in  the  care  of  the  patient  in  quarantine  and  for  diphtheria  to 
take  cultures  of  all  who  may  be  released  from  quarantine. 

The  quarantine  officer's  report  having  been  returned  to  the  desk  is  matched 
with  the  telephone  ticket  to  verify  the  completeness  of  the  work  and  from 
them  the  street  file  is  made  out. 

The  telephone  ticket  is  preserved;  the  quarantine  officers'  reports  for 
each  disease  are  numbered  consecutively  for  each  month,  putting  two  or 
more  numbers  on  a  card,  provided  more  than  one  case  is  found  in  the  home; 
the  street  file  cards  are  filed  by  address,  a  separate  file  being  kept  for  diph- 
theria. The  results  of  all  cultures  taken  to  release  from  quarantine  in  diph- 
theria are  entered  on  the  backs  of  these  cards. 

The  work  and  school  permits  need  little  explanation.  They  are  given 
to  adults  and  children  who  may  be  permitted  to  work  or  to  go  to  school 
during  the  period  of  quarantine,  and,  school  permits  particularly,  to  the 
patient  and  others  who  have  been  kept  under  quarantine  until  its  termina- 
tion. 

Convalescent  tickets  are  not  used  in  diphtheria,  the  patient  being  released 
on  culture.  When  a  physician  reports  a  case  of  diphtheria  he  is  asked  if 
he  desires  to  have  nurses  take  the  release  cultures,  and  almost  invariably 
replies  in  the  affirmative.  When  his  consent  has  been  secured  the  health 
center  in  which  this  patient  is  located  is  notified  and  eight  days  from  the 
reported  onset  of  the  disease  culturing  is  begun.  In  measles  the  date  of 
appearance  of  rash  is  noted  by  the  officer  and  the  ticket  returned  to  the 
desk;  in  scarlet  fever  the  ticket  is  not  left  in  the  home  but  is  mailed  to  the 
physician;  for  other  quarantined  diseases  it  is  left  in  the  home  for  the  signa- 
ture of  the  physician. 


126  Hospital  and  Health  Survey 

The  public  and  parochial  schools  and  the  public  library  receive  daily 
notice  of  the  names  and  addresses  of  all  cases  of  diphtheria,  scarlet  fever, 
smallpox,  epidemic  cerebro  spinal  meningitis  and  acute  poliomyelitis. 

Any  library  books  found  in  the  homes  in  which  one  of  the  above  diseases 
is  quarantined  are  brought  by  the  sanitary  officer  to  the  city  laboratory, 
disinfected  and  returned  to  the  library . 

The  physician  in  charge  of  the  contagious  wards  at  City  Hospital,  having 
reported  that  many  cases  of  diphtheria  admitted  to  the  hospital  indicate  by 
their  history  an  entirely  inadequate  use  of  antitoxin,  a  slip  giving  suggestions 
for  the  administration  of  antitoxin  in  cases  of  diphtheria  is  inserted  in  all 
physicians'  culture  outfits. 

Within  the  past  two  years  an  attempt  has  been  made  to  determine  the 
susceptibility  of  children  in  institutions  to  diphtheria  by  the  Schick  test 
and  to  provide  immunization  of  those  found  susceptible,  by  the  use  of  toxin- 
antitoxin  in  three  injections  at  intervals  of  one  week.  This  has  been  done 
on  several  thousand  children  with  satisfactory  results.  By  preference  the 
institution  is  "Schicked"  when  the  disease  is  not  present.  However,  if  con- 
sent has  not  been  secured  before  this,  study  of  the  children  is  made  on  the 
occurrence  of  cases. 

Plans  for  making  this  procedure  available  to  all  Cleveland  children  are 
under  consideration. 

S:yiallpox 

Cleveland  has  a  large  unvaccinated  population  and  as  a  consequence 
smallpox  is  a  problem  much  of  the  time,  as  indicated  by  the  number  of  cases 
handled  in  the  past  five  years— 1915,  45;  1916,  204;  1917,  661;  1918,  1,120; 
1919,  232.  Fortunately  the  disease  has  been  present  in  the  very  mild  form 
and  has  caused  no  deaths.  In  a  thoroughly  vaccinated  population  there 
would  be  no  smallpox  problem,  but  the  only  time  when  Cleveland  has  had  a 
practically  vaccinated  population  was  eighteen  years  ago,  when  the  presence 
of  the  disease  in  a  severe  form  led  the  Chamber  of  Commerce,  the  Board  of 
Education  and  the  other  groups  of  laymen  to  get  solidly  behind  the  Commis- 
sioner of  Health  in  this  matter. 

Notwithstanding  the  provision  of  the  communicable  disease  ordinance 
that  no  unvaccinated  child  may  be  in  school,  our  children  are  not  completely 
vaccinated.  Out  of  105,000  unvaccinated  children  in  the  public  schools  in 
the  year  1917-18,  101,000  were  vaccinated  by  school  physicians;  3,600  were 
permitted  to  attend  school  on  receipt  of  a  sworn  statement  from  the  parents 
that  they  were  opposed  to  vaccination,  400  on  doctors'  certificates  and  14 
were  excluded. 

The  parochial  schools,  having  no  medical  supervision,  have  presented 
greater  difficulties  than  the  public  schools.  Within  the  past  year  the  bureau 
has  vaccinated  in  about  half  the  parochial  schools,  including  most  of  the 
largest  of  these,  and  this  work  will  be  pushed  the  coming  fall. 

The  district  physicians  report  12,629  vaccinations  in  the  year  1919. 


Public  Health  Services  127 

On  the  occurrence  of  a  case  of  smallpox  all  exposures  in  the  household 
are  vaccinated,  all  contacts  in  shops  and  factories,  if  the  patient  had  been  at 
work  after  the  onset  of  his  illness  and  all  pupils  and  teachers  in  schools  for 
either  direct  or  indirect  exposure. 

The  influx  of  Southern  Negroes  accounts  to  a  very  considerable  degree  for 
the  recent  cases  of  smallpox  in  Cleveland.  Arrangements  have  been  made 
to  reach  certain  of  these  who  enter  the  city  in  groups  and  vaccinate  them 
before  they  begin  their  work 

So  much  for  the  authority,  the  system,  the  method,  and  all  based  in  the 
main  upon  sound  medical  opinion,  except  that  so-called  disinfection  by 
gaseous  fumigation  is  probably  valueless  and  an  unnecessary  expense.  In 
cases  of  smallpox,  and  where  deaths  from  tuberculosis  have  occurred  in  tene- 
ments, disinfection  to  precede  thorough  cleansing  and  renovation  of  walls 
and  painted  surfaces  is  probably  a  wise  precaution. 

Results 

What  of  the  results?  To  what  extent  is  reporting  uniform  and  observed 
conscientiously?  Are  isolation  and  placards  respected?  What  is  the  effect 
on  the  incidence  of  the  reportable  diseases? 

Table  III.  in  the  Appendix,  studied  in  connection  with  the  reports  of 
deaths  in  the  table  of  so-called  endemic  indices,  Table  IV.,  discloses  the 
obvious  and  general  incompleteness  of  morbidity  reports. 

The  results  of  administrative  measures  directed  to  the  control  of  the 
communicable  diseases  should  be  shown  in  a  reduction  in  the  number  of 
cases  and  in  the  percentage  of  deaths  among  the  cases  that  do  occur.  The 
incompleteness  of  reporting  of  cases,the  margin  of  error  in  diagnosis  and  in 
statements  of  cause  of  death  make  any  conclusions  as  to  the  numerical  in- 
crease or  decrease  in  communicable  diseases  and  deaths  from  them  of  doubt- 
ful value.  However,  in  the  absence  of  any  particular  change  in  the  attitude 
of  physicians  with  regard  to  reporting  and  of  new  or  unusual  efforts  by  the 
Division  of  Health  to  enforce  reporting  by  physicians,  we  may  assume  that 
the  fluctuations  in  numbers  of  cases  reported  represent  bona  ride  variations 
in  incidence,  but  not  the  total  incidence.  Similarly  in  the  absence  of  any 
specific  or  new  and  accurate  criteria  for  establishing  diagnosis  among  these 
diseases,  the  reports  of  deaths  in  this  group  of  diseases  in  which  the  clinical 
picture  is  fairly  typical,  probably  may  be  considered  quite  reliable.  No  at- 
tempt will  be  made  here  to  calculate  the  case  mortality  percentage  of  com- 
municable diseases  in  Cleveland,  as  such  studies  would  extend  the  report 
out  of  all  relation  to  its  particular  object  and  immediate  uses.  Such  infor- 
mation should  be  presented  in  the  annual  report  of  the  Commissioner  of 
Health. 

For  those  who  are  professionally  trained  to  read  and  understand  the 
significance  of  and  the  relative  merit  in  the  use  of  the  so-called  Sanitary  Index 
and  of  the  Endemic  Index  a  chart  and  table  are  prepared  from  data  obtained 
from  the  Chief  of  the  Bureau  of  Communicable  Disease.  (Fig.  VI.  and 
Table  IV.) 


128 


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Public  Health  Services 


129 


DEATHS  IN  CLEVELAND  FROM  ALL  CAUSES  AND  FOR  DISEASES  ON  WHICH  THE 
SANITARY  INDEX  RATE  IS  CALCULATED,  PER  10,000  POPULATION 
(Rates  corrected  according  to  population  estimates  based  on  1920  census  returns) 


Year. 1910 

Population 564 ,  066 

Total  Deaths 8,703 

Sanitary  Index  Deaths 3,414 

Year... 1915 

Population 683 ,  416 

Total  Deaths 9,534 

Sanitary  Index  Deaths 3 ,  280 


1911 

1912 

1913 

1914 

587,936 

611,806 

635,676 

659,546 

8,545 

8,769 

9,454 

8,980 

3,204 

3,032 

3,503 

3,193 

1916 

1917 

1918 

1919 

707,286 

731,156 

755,026 

778,896 

10,719 

11,623 

13,882 

10,616 

3,425 

3,956 

3,496 

3,105 

143 


135.5    134.3 


139 


125 


129.5 


141 


148.5 


173 


127.5 


lllllllllB 

Year   1910   1911   1912   1913   1914   1915   1916   1917   1918   1919   Year 


Fig.  VII. 


The  proportion  of  total  deaths  due  to  the  group  of  communicable  diseases  and  causes  of  death  under 
one  year  upon  which  the  so-called  sanitary  index  is  calculated,  is  represented  by^the  shaded 
lower  portion  of  the  column  for  each  year. 


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Public  Health  Services 


131 


For  convenience  in  reference  and  to  give  in  brief  form  the  actual  loss  of 
lifejin  Cleveland  from  the  group  of  diseases  included  in  the  list  upon  which 
the  sanitary  index  (Fig.  VI.)  is  based  for  the  past  ten  years,  by  years,  and 
as  a  total,  Table  V.  is  prepared.  To  indicate  the  relative  proportion  of  all 
deaths  due  to  the  communicable  preventable  diseases  with  which  we  are 
here  chiefly  concerned,  Fig.  VII.  is  prepared.  Fig.  VIII.  shows  graphically 
the  death-rates  per  100,000  population  for  eight  important  communicable 
diseases  in^Cleveland  and  in  all  cities  included  in  the  registration  area  for 


H  E- 

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Tuberculosis  cases 

reported  in  1919-20 
per  10,000  population 


Cases  of  measles, 
whooping  cough, 
diphtheria  and 
scarlet  fever  re- 
ported 1919-20  per 
10,000  child  population 
(0-16  inclusive) 


Fig.  IX. 


Cases  of  venereal 

disease  in 
attendance  at  Lake- 
side, Mt  Sinai  and 
Charity  dispensaries 
during  the  year 
1919-20  per 
10,000  population. 


the  quinquennium  1913-17,  and  the  death  rates  per  100,000  population  dur- 
ing 1917  for  these  same  diseases  in  Cleveland,  the  cities  and  the  states  of 
the  registration  area. 

Fig.  IX.  illustrates  the  morbidity  incidence  of  tuberculosis,  of  four  com- 
mon acute  communicable  diseases  of  childhood  and  of  venereal  diseases  as 
reported  from  the  health  districts,  showing  the  relative  rates  for  the  districts. 
The  same  data  are  presented  on  Fig.  X.,  a  map  of  the  city  giving  health  dis- 
tricts.* 


•The  data  for  Figures  IX.  to  XIII.  were  based  on  population  estimates  before   the   1920   census  figures 
were  available. 


132 


Hospital  and  Health  Survey 


Fig.  X. 

'The  narrow  eastern  portion  of  District  Six  has  been  omitted. 


Public  Health  Services 


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Public  Health  Services 


135 


Fig.  XIII. 

*The  narrow  eastern  portion  of  District  Six  has  been  omitted. 


A— Deaths  from  scarlet  fever,  whooping  cough,  measles  and  diphtheria  per  100,000  population. 
B— Deaths  from  pulmonary  tuberculosis  per  100,000  population. 
C— Deaths  from  pneumonia  (all  forms)  per  100,000  population. 
D— Deaths  from  diarrhea  under  2  years  per  100,000  population. 


136  Hospital  and  Health  Survey 

Fig.  XL  illustrates  the  relative  position  of  the  health  districts  as  measured 
by  registered  births  and  deaths. 

Fig.  XII.  shows  an  analysis  of  death  rates  from  all  causes  and  from  vari- 
ous communicable  diseases,  by  health  districts.  Most  of  the  same  data  are 
presented  on  Fig.  XIII. ,  a  map  of  the  city  divided  into  health  districts. 

The  reader  is  referred  to  parts  IV.  and  V.  for  complete  discussion  of  the 
incidence  and  sufficiency  of  methods  for  control,  and  the  results  of  public 
health  service  in  tuberculosis,  syphilis  and  gonorrhea. 

The  accompanying  table,  quoted  from  the  annual  report  upon  typhoid 
fever  in  the  large  cities  of  the  United  States,  published  in  the  Journal  of  the 
American  Medical  Association,  Vol.  74,  No.  10,  page  673,  shows  Cleveland's 
enviable  position  resulting  in  all  probability  more  from  the  chlorination 
after  filtration  of  its  water  supply  and  the  general  pasteurization  of  its  milk 
supply  than  from  other  causes. 

Death  Rates  from  Typhoid  in  Cities  of  Group  One 
{More  than  500,000  Population) 
DEATHS  FROM  TYPHOID  PER   100,000  POPULATION 


Average 

Average 

Average 

1919 

1918 

1916-1919 

1911-1915 

1906-1910 

Chicago 

1.2 

1.4 

2.7 

8.2 

15.8 

New  York 

2.0 
2.2 

3.7 
2.5 

3.4 
2.8 

8.0 
8.0 

13.5 

Boston 

16.0 

Cleveland.. 

2.4 

4.7 

4.9 

10.0 

15.7 

Philadelphia 

4.4 

3.0 

5.3 

11.2 

41.7 

Detroit 

5.3 

10.0 

12.0 

18.1 

21.1 

St.  Louis 

5.8 

7.2 

7.5 

12.1 

14.7 

Pittsburgh. 

6.2 

9.8 

8.9 

15.9 

65.0 

Baltimore 

8.9 

12.2 

13.6 

23.7 

35.1 

Cleveland's  relatively  high  death  rate  from  diphtheria  (Fig.  VIII.)  as 
compared  with  other  cities  and  states  may  in  part  be  attributed  to  the  lack 
of  any  services  of  a  skilled  intubator  for  patients  coming  to  the  care  of  the 
district  physicians  and  the  unusual  indifference  of  the  general  practitioner 
to  the  importance  of  early  and  adequate  use  of  diphtheria  antitoxin  for 
therapeutic  purposes,  on  clinical  diagnosis  or  on  reasonable  suspicion  with- 
out awaiting  positive  laboratory  confirmation.  The  experience  of  the  City 
Hospital  contagious  service  and  of  the  consultants  in  pediatrics  in  the  city  are 
full  of  instances  where  lives  were  sacrificed  by  the  inexcusable  delay  in  the 
use  of  this  specific  therapy.  It  is  recommended  that  a  physician  skilled  in 
intubation  be  employed  by  the  Division  of  Health  to  be  available  on  call  for 
emergencies  in  diphtheria,  and  that  the  Division  of  Health  undertake,  through 


Public  Health  Services  137 

the  Academy  of  Medicine  and  directly  with  the  practising  physicians,  edu- 
cation in  the  advantages  of  diphtheria  antitoxin  and  the  dangers  commonly 
resulting  from  delay  in  its  administration. 

With  the  exception  of  rabies  none  of  the  animal  diseases  require  par- 
ticular mention  here,  since  tuberculosis  in  cattle  is  guarded  against  by  ade- 
quate meat  inspection  and  by  the  compulsory  pasteurization  of  milk.  The 
situation  of  rabies  control  is  bad,  owing  to  the  lack  of  an  ordinance  requiring 
muzzling,  and  the  lack  of  enforcement  of  the  state  dog  licensing  law.  The 
most  valuable  agency  in  controlling  rabies  in  Cleveland  is  the  Animal  Pro- 
tective League  which  maintains  an  active  collection  service  for  the  removal 
of  stray  dogs. 

The  diagnosis  of  rabies  in  animals  and  man  and  the  protective  treatment 
of  those  bitten  by  rabid  animals  are  provided  according  to  good  modern 
standards  by  the  Bureau  of  Food  and  Dairy  Inspection.  The  cost  of  treat- 
ment is  provided  by  the  county  commissioners. 


Inadequate  Supervision  of  Quarantine 

In  Cleveland  as  in  many  municipalities  there  is  frank  criticism  of  the 
futility  of  official  attempts  at  quarantine.  Responsible  physicians  and  nurses 
report  that  keeping  of  quarantine  in  Cleveland  is  so  unusual  that  a  family 
who  does  keep  it  is  cause  for  much  comment  and  no  little  surprise.  Instances 
of  inadequate  supervision  and  a  lack  of  firmness  or  conviction  in  enforcing 
regulations  are  quoted  from  case  reports  obtained  by  the  Survey. 

E.  G.,  Portland  Avenue,  was  quarantined  for  diphtheria  August  23,  1919. 
This  report  was  telephoned  to  the  Division  of  Health  the  same  day,  "Patient 
ill  in  room  off  kitchen.  Comes  into  kitchen  frequently.  Family  upstairs 
come  and  go  through  this  kitchen  whenever  entering  or  leaving  house. 
Patient's  mother  refuses  to  keep  quarantine."  Division  of  Health  promised 
to  force  child  into  hospital,  but  did  not.  The  first  release  culture  was  taken 
September  8th,  and  as  the  child  was  a  diphtheria  carrier,  quarantine  was 
continued  for  a  long  period  of  time;  the  sign  finally  being  removed  Septem- 
ber 23rd.  During  this  period  the  woman  tore  down  the  sign  and  went  out. 
This  was  reported  to  the  Division  of  Health.  The  woman  and  child  with 
positive  culture  went  to  market  and  were  absent  when  the  nurse  went  to 
culture.  A  report  of  this  was  made  to  the  Division  of  Health  and  as  far  as 
results  were  concerned,  the  nurse  might  just  as  well  have  saved  the  time 
she  spent  in  telephoning. 

Mrs.  P.,  Scovill  Avenue,  was  quarantined  for  diphtheria  September  17, 
1919,  and  family  was  cultured  on  same  date.  She  herself  had  a  positive 
culture  which  held  so  for  some  time.  The  sign  was  taken  down  October 
3rd.  On  the  25th  of  September  the  nurse  went  to  culture  and  found  patient 
with  positive  culture  at  church.  The  nurse  returned  in  the  afternoon  and 
was  told  by  patient  that  as  she  was  not  sick  there  was  "no  need  of  such  a 
fuss."  This  was  reported  to  the  Division  of  Health  with  the  result  that  on 
the  29th,  when  the  nurse  returned  for  another  culture,  the  house  was  closed 


138  Hospital  and  Health  Survey 

and  the  door  was  padlocked  on  the  outside.  This,  too,  was  reported  to  the 
Division  of  Health  with  such  good  effect  that  the  woman  was  out  again  on 
the  30th  and  neighbors  said  she  was  at  the  store  and  not  expected  back  for 
some  time. 

A  diphtheria  sign  was  put  up  September  19th  on  the  house  of  Mrs.  F., 
Scovill  Avenue.  The  sign  did  not  come  down  until  October  8th,  as  the  child 
here  was  a  carrier  also.  The  family  made  no  pretense  of  keeping  quarantine 
and  the  Division  of  Health  was  informed.  The  next  time  the  nurse  saw  the 
woman  she  was  selling  fruit  from  a  stand  in  front  of  the  house  and  the  child, 
with  a  positive  culture,  was  with  her.  This  was  reported  to  the  Division  of 
Health  and  the  child  remained  in  the  home. 

The  following  notes  from  a  nurse's  record  indicate  some  of  the  reasons 
for  lack  of  confidence  in  quarantine.  "These  cases  of  diphtheria  are  typical 
of  our  present  system.  One  and  all  of  these  families  said  nonchalantly, 
when  found  breaking  isolation,  'Nobody  does  any  different,'  or  'Mrs.  So 
and  So  had  a  sign  on  her  house  and  she  didn't  do  any  different,  so  why 
should  I?'  And  when  one  discovers  that  in  a  tiny  section,  with  a  popula- 
tion of  12,000,  between  the  months  of  September  and  December  there  were 
twenty-seven  families  (under  so-called  quarantine  for  diphtheria)  who  ran 
wild  with  no  more  serious  result  than  a  visit  from  a  sanitary  officer,  can  one 
wonder  either  at  the  unconcern  of  the  families  or  the  prevalence  of  the 
disease  this  winter?" 

And  why  must  there  be  such  a  delay  in  getting  orders  to  remove  diph- 
theria signs  when  the  cultures  have  proved  satisfactory?  In  at  least  a  third 
of  these  cases  the  report  of  the  culture  comes  to  the  nurse  two  or  three  days 
before  it  reaches  the  authority  in  the  Division  of  Health  whose  business  it  is 
to  order  the  signs  removed. 

Verified  instances  of  failure  to  observe  quarantine  were  obtained  in  a 
brief  period  in  January,  1920,  in  the  case  of  the  following  diseases: 

Diphtheria 14  instances 

Whooping  cough 15  " 

Mumps 5 

Chickenpox 1  " 

Scarlet  fever 1  " 

The  district  physicians  of  the  Division  of  Health  find  the  situation  very 
unsatisfactory,  the  warnings  or  threats  of  sanitary  police  and  nurses  failing 
to  produce  any  substantial  results.  Firmness,  tact  and  a  consistent  policy 
should  remedy  this. 

SERVICE  OF  DISTRICT  PHYSICIANS 

Organization 

There  are  seven  full-time  district  physicians  employed  by  the  Cleveland 
Division  of  Health  under  the  Bureau  of  Communicable  Disease.  One  of 
them  acts  as  Assistant  Chief  of  the    Bureau  and  one  handles  only    cases 


Public  Health  Services  139 

of  drug  addiction,  leaving  five  to  cover  the  district  work.  These  physi- 
cians receive  $3,300.00  a  year  and  are  required  to  provide  their  own  auto- 
mobiles, telephone  service  and  physicians'  bags.  They  are  furnished  with 
drugs  and  surgical  dressings  by  the  Division  of  Health. 

Each  physician  is  assigned  to  one  of  the  following  five  districts :  District 
One  is  the  entire  West  Side,  exclusive  of  a  small  portion  of  the  so-called 
South  Side  east  of  West  14th.  District  Two  is  the  East  Side,  from  the  river 
to  East  71st  Street,  north  of  Euclid  Avenue;  District  Three  extends  from 
Euclid  Avenue,  on  the  north,  to  the  city  limits,  and  from  East  55th  Street 
to  West  14th  Street.  This  district  includes  the  congested  area  of  the  city. 
District  Four  extends  from  East  71st  Street,  on  the  west,  to  the  city  limits  in 
Collinwood  (East  200th  Street),  to  the  south  side  of  Euclid  Avenue  west  to 
East  55th  Street,  from  there  to  Quincy  Avenue  and  east  to  the  city  limits. 
District  Five  extends  from  Quincy  Avenue  and  East  55th  Street  south  and 
east  to  the  city  limits.  These  districts  have  different  boundaries  from  those 
of  any  other  administrative  districts  used  in  public  or  private  health  work. 

Duties 

The  duties  of  the  district  physicians  are  to  care  for  the  sick  poor,  investi- 
gate suspected  cases  of  communicable  disease  and  to  make  vaccinations, 
etc.,  under  the  direction  of  the  chief  of  the  bureau.  They  are  not  permitted 
to  do  any  obstetrical  work  or  any  major  surgery.  They  are,  further,  not 
expected  to  treat  in  their  homes  the  more  serious  diseases,  such  as  pneu- 
monia, typhoid  fever,  heart  disease  or  nephritis,  but  to  refer  such  cases  to 
hospitals  when  possible.  Many  ambulatory  cases  are  properly  referred  to 
the  dispensaries  of  such  hospitals  as  Lakeside,  Mt.  Sinai  and  Charity,  where 
the  facilities  for  diagnosis  and  treatment  are  better  than  those  at  the  command 
of  the  district  physicians. 

Method  of  Receiving  Calls 

Calls  for  the  services  of  the  district  physicians  come  to  them  in  a  variety 
of  ways;  their  names  and  addresses  are  known  to  the  police  of  the  city, 
and  the  number  of  calls  which  they  receive  from  this  source  is  considerable. 
This  applies  particularly  to  night  calls.  They  are  reached  by  people  needing 
their  services  in  exactly  the  same  way  that  private  physicians  receive  their 
calls,  through  the  advice  of  friends  and  neighbors  who  give  their  names  and 
addresses.  They  are  also  called  by  public  health  nurses,  by  the  Visiting 
Nurse  Association  and  by  other  agencies.  The  greatest  single  source  of  calls, 
however,  is  to  be  found  in  the  call  book  kept  for  district  physicians  at  the 
Division  of  Health.  It  is  impossible  to  determine  exactly  the  relative  num- 
ber of  calls  from  the  different  sources.  As  fair  an  estimate  as  can  be  made  is 
that  about  one-third  are  received  from  other  sources  than  the  call  book. 

Offices 

Each  physician  is  provided  with  an  office  at  the  health  center  in  his  dis- 
trict, where  he  keeps  supplies  and  where  patients  may  go  to  see  him.  The 
office  work  of  the  district  physician  is,  however,  comparatively  small. 


140  Hospital  and  Health  Survey 

Records 

The  Division  of  Health  has  never  required  district  physicians  to  keep 
histories  of  their  cases.  Monthly  summaries  are  required  and  these  are 
made  up  from  records  kept  in  a  pocket  note  book.  From  these  entries  the 
physicians  are  expected  to  be  able  to  tell  their  diagnoses  and  the  disposition 
of  the  cases  assigned  to  them.  As  a  test  of  their  ability  to  report  such  essen- 
tial facts  they  have  been  asked  from  time  to  time  in  their  conferences  to  report 
upon  cases  selected  at  random  from  the  call  book,  and  the  chief  of  the  bureau 
has  found  them  able  to  do  so. 


Supervision 

The  work  of  the  district  physicians  is  under  the  general  direction  of  the 
Chief  of  the  Bureau  of  Communicable  Disease,  although  in  actual  practice 
there  is  very  little  supervision  of  their  work  in  the  homes.  Weekly  staff 
meetings  are  held,  except  during  the  summer  months,  and  at  these  meetings 
matters  of  seasonal  interest  are  discussed,  and  the  district  physicians  are 
free  to  bring  up  special  cases  for  conference. 

Volume  of  Work 

A  table  showing  the  volume  of  the  activities  of  the  different  district  physi- 
cians for  the  year  1919  will  be  found  in  the  Appendix  (Table  VI.) 

It  is  obvious  that  the  amount  of  work  of  the  different  physicians  varies 
greatly.  This  may  be  accounted  for  partially  by  the  character  of  the  dis- 
tricts themselves  (for  example,  District  Three,  which  shows  the  highest*  num- 
ber of  calls,  includes  the  most  congested  and  poorest  area  in  the  city),  par- 
tially by  the  distances  necessary  to  cover  in  making  calls,  and  partially,  no 
doubt,  by  the  diligence  of  the  individual  physicians. 

The  average  of  calls  per  case  varies  from  one  in  District  Five  to  3.8  in 
District  One.  If  an  average  of  two  calls  per  patient  be  accepted  as  a  stand- 
ard, two  districts  (Three  and  Five)  fall  below,  two  districts  (Two  and  Four) 
are  practically  equal  and  one  district  (number  One)  is  well  above  the  stand- 
ard. 

The  number  of  vaccinations  varied  greatly,  District  Five  having  reported 
over  ten  times  as  many  as  District  Two.  It  is  interesting  to  note  that  the 
highest  number  of  vaccinations  was  recorded  in  the  district  where  the  aver- 
age number  of  calls  per  case  was  the  lowest. 

According  to  the  records  the  physicians  vary  greatly  in  referring  cases  to 
agencies.  The  physician  in  District  Two  reports  no  use  of  agencies  other 
than  hospitals  and  dispensaries.  The  physicians  in  Districts  Three  and  Five 
show  good  cooperation  with  the  nursing  agencies. 

The  variation  in  the  amount  of  work  reported  raises  the  question  of  the 
desirability  of  redistricting  the  city. 


Public  Health  Services  141 

Summary  of  Complaints  of  Service 
By  various  social  and  charitable  agencies: 

1.  There  were  seven  sources  of  complaints  because  service  was  not 
prompt.  One  agency  stated  that  delays  of  two  days  or  more  occurred; 
another  that  calls  were  sometimes  never  answered.  Five  agencies  stated 
that  the  service  was  prompt.  The  difference  in  localities  could  easily  ac- 
count for  this  discrepancy. 

2.  Six  agencies  complained  of  the  lack  of  continuity  of  care,  the  general 
consensus  of  opinion  being  that  calls  were  not  repeated  sufficiently  often 
unless  pressure  was  brought  to  bear  on  the  physicians. 

3.  There  were  two  complaints  of  brutality;  one  of  superficial  work; 
three  of  difficulty  in  getting  in  touch  with  physicians;  one  of  lack  of  physi- 
cian's understanding  of  foreign  language;  one  of  lack  of  sufficient  home 
instruction  being  given. 

4.  All  agencies  joined  in  saying  that  the  district  physicians  were  willing 
to  give  medical  information  to  cooperating  agencies,  although  one  complained 
that  the  physicians'  records  were  so  inadequate  that  details  of  cases  were 
not  available. 

By  district  physicians  themselves: 

The  district  physicians  themselves  seemed  to  feel  a  lack  of  thorough 
supervision  of  their  work  and  a  failure  of  cooperation  by  the  Health  Divi- 
sion. They  expressed  a  need  for  standard  instruction;  for  more  systematic 
information  as  to  changes  in  procedures  or  policies  of  the  Division  of  Health, 
City  Hospital  and  other  agencies ;  and  in  general  a  lack  of  sympathetic  rela- 
tionship with  the  chief  of  their  bureau  and  the  Commissioner  of  Health. 

Other  needs  brought  out  by  the  physicians  themselves  were:  for  a  con- 
sultant on  their  cases;  more  adequate  case  histories;  a  more  comprehensive 
drug  formulary;  provision  of  bottles  for  dispensing  drugs;  smaller  districts 
or  a  redistricting  of  the  city. 

One  physician  felt  that  his  work  was  hampered  by  the  fact  that  he  had 
no  command  of  foreign  languages;  another  felt  a  great  lack  of  appreciation 
among  the  foreign  population. 

RECOMMEND  A  TIONS 

It  is  recommended  that: 

District  physicians  be  appointed  for  a  definite  term  of  service,  with  a  limit  to  the 
number  of  terms  permitted  on  re -appointment. 

Appointments  be  made  after  examination,  written  and  oral,  by  a  special  committee 
of  physicians  appointed  for  this  purpose  (from  the  Academy  of  Medicine  if  possible). 


142  Hospital  and  Health  Survey 


There  be  a  special  night  service  rotating  through  the  staff  or  assigned  to  the  junior 
members  for  certain  periods. 

Ambulatory  cases  be  excluded  from  care,  such  cases  to  be  referred  to  the  appropriate 
dispensary,  and  not  treated  at  the  offices  of  the  district  physicians. 

The  visiting  nurses  be  used  as  a  routine  for  all  cases  except  those  discharged  at  the 
first  visit  or  referred  to  a  hospital  for  care  at  once. 

Each  district  physician  be  assigned  for  part  of  his  time  to  dispensary  work  and  to  sani- 
tary inspection  work.  The  latter  function  should  include  reports  upon  the  sanitary  con- 
dition of  the  physician's  district  and  special  investigations  on  request  of  the  Commissioner. 

Each  district  physician  should  be  assigned  to  duty  to  a  particular  clinic  for  dispensary 
service  for  several  months  each  year. 

There  be  added  three  more  physicians  to  the  staff  to  cover  the  special  night  service 
and  the  extra  work  that  cannot  now  be  done,  or  be  done  well. 

The  city  be  redistricted  on  the  basis  of  multiples  of  the  sanitary  areas  as  used  by  the 
Bureau  of  the  Census. 

Staff  meetings  be  held  monthly  for  consideration  of  a  definite  program  arranged  by 
the  Chief  of  the  Bureau.  Each  physician  should  be  expected  in  turn  to  present  a  report 
and  take  the  leading  part  in  one  meeting  each  year.  Time  for  discussion  of  administra- 
tive matters  and  technical  medical  questions  should  be  arranged  for  at  each  staff  meeting. 

The  district  physicians  should  report  by  simple  forms  to  the  central  office  by  mail 
daily.  These  reports,  which  should  be  brief,  should  be  tabulated  and  analyzed  at  the 
central  office. 

BUREAU  OF  TUBERCULOSIS 

The  Bureau  of  Tuberculosis  has  been  discussed  under  Part  IV.  and  hence 
a  description  of  it  has  been  omitted  here. 


Public  Health  Services  143 

The  Bureau  of  Child  Hygiene 

THE  Bureau  of  Child  Hygiene  deals  with  matters  of  such  importance  to 
the  entire  health  and  welfare  programs,  both  public  and  private,  that 
Part  III.  of  the  report  is  devoted  exclusively  to  these  subjects,  including 
consideration  of  the  organizations  and  functions  of  this  bureau  in  the  Division 
of  Health.  Furthermore,  in  the  Survey  of  Nursing  (Part  IX.),  the  nursing 
service  of  the  Division  of  Health  is  analyzed  in  detail,  including  a  special 
study  of  the  follow-up  of  infant  welfare  work  from  the  health  centers.  In 
Part  IX.  in  the  chapter  on  Prenatal  and  Maternity  Care,  there  is  discussion 
of  the  relation  of  the  Bureau  of  Child  Hygiene  to  this  activity.  In  Part  X. 
there  will  be  found  consideration  of  the  health  centers  which  serve  many 
purposes  under  the  direct  control  of  the  Bureau  of  Child  Hygiene.  Treat- 
ment here  of  the  official  public  health  services  for  children  would  be  a  mere 
repetition  of  what  is  more  appropriately  dealt  with  in  other  chapters. 


144  Hospital  and  Health  Survey 


The  Bureau  of  Sanitation 

FOR  several  years  this  division  lias  had  no  chief  and  the  results  are 
obvious.  The  scant  attention  which  the  commissioner,  from  the  midst 
of  his  multifarious  duties,  can  give  as  the  acting  chief  is  insufficient 
to  develop  the  proper  functions  of  the  force  at  his  disposal.  The  sergeant 
and  the  16  patrolmen  under  him,  with  two  clerks,  no  more  than  keep 
abreast  of  the  citizens'  complaints,  which  flood  their  office.  Five  more 
patrolmen  are  assigned  to  placarding  and  enforcement  of  quarantine,  and 
another  five  are  on  duty  with  the  Bureau  of  Food  and  Dairy  Inspection. 
Both  of  these  services  would  be  better  done  by  other  employes  if  such  were 
available,  than  by  men  brought  up  with  the  ordinary  police  point  of  view. 
Nurses  are  being  used  more  and  more  for  carrying  out  isolation  require- 
ments, and  trained  food  inspectors  would  be  more  appropriate  for  the  ed- 
ucational supervision  of  the  food  and  dairy  industries  than  police.  When 
enforcement,  summons  or  arrest  are  needed  patrolmen  can  be  easily  obtained. 

Complaints  come  to  the  office  by  wire,  mail,  by  word  of  mouth  and  re- 
ferred from  the  central  complaint  bureau  of  the  City  Hall.  The  records  of 
complaints,  of  action  taken  and  of  disposition  are  simple  and  adequate.  A 
series  studied  at  the  office  and  in  the  hands  of  inspectors  showed  that  entries 
were  made  at  the  time  of  or  on  the  day  of  inspection. 

The  office  is  open  from  8  a.  m.  to  7:30  p.  m.,  and  there  are  often  times 
when  the  sergeant,  in  order  to  get  out  into  the  field,  must  assign  a  patrolman 
of  the  squad  to  desk  duty.  The  squad  is  wholly  used  in  satisfying  complaints 
and  enforcement  of  notices  or  orders  issued.  There  is  no  constructive  work 
going  on  in  the  office.  They  have  no  lists  of  premises,  such  as  stables,  offen- 
sive trade  factories  and  other  city  nuisances,  and  they  have  no  house  files 
for  various  lots  or  premises  in  the  city  against  which  complaints  have  been 
lodged.  They  have  no  census  of  private  water  supplies  and  only  a  partial 
census  of  privies  in  the  city. 

There  is  no  supervision  of  the  field  force  with  the  exception  of  what  the 
sergeant  can  do  in  the  few  hours  each  day,  two  or  three,  when  he  is  free 
from  office  duties.  There  are  no  meetings  held  at  which  instructions  or  ad- 
vice is  given  to  the  squad.  Neither  the  sergeant  nor  those  under  him  have 
had  any  technical  education  in  sanitation.  Various  members  of  the  squad 
find  it  a  stepping  stone  to  the  practice  of  law,  for  which  they  study  at  night 
school  while  working  for  the  city. 

The  Sanitary  Bureau  cooperates  with  other  city  departments  directly,  in 
accomplishing  abatement  of  nuisances,  in  such  matters  as  engineering  serv- 
ice, sewage,  water  supply  and  street  cleaning  problems.  They  cooperate 
with  the  Associated  Charities  and  other  private  agencies,  where  the  difficulty 
is  economic  and  a  poor  family  cannot  comply  with  orders.  There  is  no 
spirit  or  readiness  to  cooperate  with  departments  of  the  Ohio  state  govern- 
ment, and  as  a  result  premises,  such  as  licensed  lodging  houses,  are  wholly 
neglected  by  the  Sanitary  Bureau. 


Public  Health  Services  .  145 

Although  many  records  were  found  showing  prompt  follow-up  with  action 
through  the  City  Prosecutor,  there  were  a  considerable  number  in  which 
action  to  abate  serious  housing  nuisances  and  violations  had  been  held  for 
three  years  and  more  because  of  expected  construction  work  which  would 
obviate  need  of  further  attention,  particularly  in  regard  to  premises  in  the 
"Hill"  region.  Plenty  of  cause  for  action  was  found  in  the  much  neglected 
region  bounded  by  West  25th  Street,  Lorain,  Trowbridge  and  Fulton  to  the 
river,  where  open  and  trough  sewers  and  offensive  privies  were  found  and 
where  housing  conditions  were  very  bad. 

No  such  thing  as  a  sanitary  survey  has  been  attempted.  There  is  no 
preventive  work  under  way.  Simply  satisfying  citizens'  complaints  appears 
to  be  the  objective  of  the  bureau  at  present,  although  a  few  years  ago, 
under  a  chief,  an  aggressive  and  successful  attack  was  made  against 
violations  of  occupancy  regulations. 

In  studying  the  work  in  the  field  with  two  of  the  sanitary  patrolmen, 
both  a  member  of  the  squad  who  had  been  in  the  work  for  12  years  and  a 
younger  officer  who  had  been  on  duty  for  but  a  few  months,  showed  the  best 
possible  side  of  the  bureau  work.  They  were  considerate,  tactful,  quiet, 
and  evidently  obtained  excellent  cooperation  through  persuasion.  They 
have  a  good  general  understanding  of  their  duties  and  powers  and  are  looked 
upon  as  friends  and  advisers  by  the  people. 

They  have  evidently  never  been  taught  what  a  sanitary  privy  is  and  they 
have  no  standards  of  enforcement.  All  privies  were  in  a  shockingly  neglected 
condition,  and  although  orders  were  placed,  many  months,  and  in  some  in- 
stances more  than  a  year,  had  passed  since  the  issuance  of  orders  and  nothing 
practical  had  been  accomplished.  Much  harmless  advice  was  given  by  the 
patrolmen  on  the  basis  of  common  sense,  but  their  information  as  to  con- 
tagious diseases  was  quite  elementary  and  the  calls  they  were  observed  to 
make  for  this  purpose  carried  no  intelligible  advice  or  help  to  the  families. 

The  most  offensive  condition  found  was  in  the  Collinwood  region,  where 
a  veritable  scandal  results  in  the  matter  of  removal  of  night  soil  from  the 
privy  vaults.  The  householder  is  forbidden  to  excavate  or  remove  vault 
contents  himself.  The  Park  Department  is  responsible  for  this  service.  The 
householder  is  expected  to  pay  beforehand  at  a  charge  arbitrarily  set  by  the 
contractor.  There  are  much  discrimination  and  mjustice  in  the  charges. 
Deposits  accumulate  over  six  to  eight  months  and  service  is  denied  the  people 
except  at  extravagant  rates.  The  householders  being  people  of  small  means, 
chiefly  of  foreign  birth  and  unorganized,  have  not  made  their  complaints 
heard  at  City  Hall.  They  should  not  need  to,  as  this  is  distinctly  a  serv- 
ice the  Division  of  Health  owes  them  through  pressure  upon  the  Park 
Department. 

The  tenement  house  code  (March  8,  1915)  or  so  much  of  it  as  it  is  the  duty 
of  the  Sanitary  Bureau  to  enforce,  is  very  generally  ignored  in  its  essential 
requirements  for  health  protection,  and  yet  a  large  amount  of  work  appears 
to  have  been  accomplished.  The  entire  force  of  twenty-six  patrolmen 
should  be  assigned  to  sanitary  work  proper.     The  sixteen  officers  assigned  to 


146  Hospital  and  Health  Survey 

the  work  of  the  Bureau  of  Sanitation  have  each  a  definite  district,  consisting 
of  from  one  to  several  of  the  twenty-six  wards  into  which  the  city  is  divided. 

It  is  difficult  to  visualize  the  actual  work  of  the  Bureau  on  the  basis  of 
the  annual  report,  but  some  idea  of  the  work  can  be  obtained  from  the  fol- 
lowing statement:  in  1919,  73,859  inspections  were  made,  7,073  on  com- 
plaints. Of  the  latter  86  are  noted  as  wrong  addresses  and  40  as  no  cause 
for  complaint.  44,982  is  the  number  of  first  inspections  made  by  the  men 
on  their  regular  rounds.  As  a  result  of  the  73,859  inspections,  13,969  notices 
were  served,  11,456  directly  by  the  officer  on  his  rounds  and  2,513  mailed 
from  the  office.  The  reinspections  totaled  27,393  and  the  second  (third, 
etc.)  notices,  4,506.  As  a  result  of  the  notices  sent  out  interviews  were  sought 
by  those  against  whom  orders  had  been  issued,  to  the  number  of  4,344,  of 
which  3,505  were  personal  interviews,  chiefly  with  the  officer  on  his  rounds 
but  in  part  interviews  in  the  office.     839  were  interviews  by  telephone. 

After  two  or  more  reinspections,  when  orders  are  not  complied  with,  at 
the  request  of  the  bureau,  the  police  prosecutor  issues  a  letter  calling  upon 
the  person  against  whom  the  order  has  been  served  to  appear  before  him. 
In  most  instances,  instead  of  the  police  prosecutor  or  his  assistant  seeing  these 
people  when  they  appear  in  his  office  they  are  interviewed  by  a  sanitary  officer 
detailed  for  this  purpose.  Ordinarily  the  party  concerned  is  allowed  a  few 
days  to  comply  with  the  order  issued  by  the  bureau.  At  the  expiration  of 
this  time  the  officer  again  reinspects  and  re-reinspects.  In  some  instances 
great  delay  occurs  before  the  order  is  complied  with,  prosecutor's  letters  being 
sent  at  frequent  intervals.  In  1919  prosecutor's  letters  numbered  2,708,  the 
party  called  appearing  in  all  but  492  instances. 

Fifty-five  warrants  were  requested  during  the  year.  So  far  as  can  be 
ascertained  none  were  issued,  no  trials  were  undertaken  or  convictions  secured. 
14,525  orders  issued  were  complied  with.  In  addition  to  such  inspections  as 
affected  tenement  houses  and  other  dwellings  we  find  lodging  houses,  laun- 
dries, picture  shows  and  theaters,  workshops,  barber  shops  and  taxicabs 
dealt  with. 

Forty-five  dwellings  and  tenements  were  vacated  and  86  were  razed  as 
unfit  for  habitation.  More  than  3,000  interior  and  exterior  repairs  and  altera- 
tions were  secured.  Lights  and  ventilation  were  secured  for  322  public  halls 
or  rooms  and  148  overcrowded  rooms  vacated.  1,696  rooms  were  cleaned 
by  tenants. 

Twenty-four  permits  were  issued  for  privies  and  cesspools,  265  were 
abandoned  and  13  repaired;  139  sewer  vaults  and  sewer  crocks  were  aban- 
doned and  62  repaired.  Hopper  closets  are  permitted  but  not  recommended; 
of  these  105  were  installed,  288  repaired  and  51  removed.  Sanitary  closets, 
742  installed,  601  repaired. 

The  following  activities  were  also  part  of  the  bureau's  work:  orders  for 
installation  of  city  water,  repairs  of  sinks,  etc.,  1,699;  wells  and  cisterns  con- 
demned, 6;  vacant  lots  cleaned,  drained,  etc.,  901;  yards  cleaned,  drained 
and  graded,  6,654;   receptacles  ordered  for  garbage  or  rubbish,  8,320;   sheds 


Public  Health  Services  147 

and  barns  vacated,  cleaned,  water-tight  flooring  provided,  sewer  connections 
made,  city  water  installed,  etc.,  1,481. 

It  is  said  that  the  sanitary  inspection  of  public  baths,  bathing  beaches 
and  summer  camps  is  thorough  and  entirely  creditable  to  the  bureau.  The 
field  investigations  of  the  Survey  did  not  include  the  season  of  the  year 
when  these  recreational  activities  were  in  operation. 


148  Hospital  and  Health  Survey 

Bureau  of  Food  and  Dairy  Inspection 

The  work  of  the  Bureau  of  Food  and  Dairy  Inspection  is  carried  on  by- 
three  graduates  in  veterinary  medicine:  one  who  is  chief  of  the  bureau, 
another  who  supervises  nieat  inspection  in  city  slaughter  houses,  and  a  third 
who  inspects  the  carcasses  of  all  animals  killed  in  out-of-town  slaughter  houses 
and  has  charge  of  the  work  of  the  bureau  with  respect  to  rabies  in  animals. 
In  addition  to  the  veterinarians  there  are  25  lay  inspectors,  one  of  whom 
supervises  dairy  inspection,  the  others  being  assigned  to  the  inspection  of 
slaughter  houses,  cold  storage  plants,  ice  cream  factories,  stores  where  milk 
and  dairy  products  are  sold,  meat  markets,  etc.  The  clerical  work  of  the 
bureau  is  carried  on  by  a  clerk  and  a  typist. 

The  following  is  a  summary  of  the  work  of  the  Food  and  Dairy  Bureau  for 
the  year  1919:  total  number  of  dairies  visited  and  scored,  3,986;  total  num- 
ber of  visits,  4,633;  number  of  dairies  excluded,  407.  Nearly  three-fourths 
of  these  exclusions  were  for  the  following  causes  in  the  order  mentioned: 
not  white-washing  stable,  unsanitary  conditions,  plank  floor  in  stable.  Milk 
houses  not  used,  milk  houses  not  in  proper  condition  or  farms  without  milk 
houses,  constitute  another  important  reason  for  exclusion.  Of  the  407  ex- 
cluded, 283  were  re-admitted.  The  number  of  cows  in  this  territory  is 
43,703,  an  average  of  eleven  cows  per  dairy.  The  dairies  are  scored  by  the 
inspectors  annually.  The  maximum  score  given  was  100,  the  minimum  52, 
the  average  65. 

Special  visits  were  made  in  124  instances  to  investigate  changes  and  altera- 
tions, and  in  13  instances  to  investigate  contagious  diseases.  42  visits  to 
country  milk-collecting  stations  were  made  during  the  year  and  these  led  to 
34  notices  to  improve  conditions. 

The  work  of  the  bureau  which  has  to  do  with  the  milk  depots  of  the  city, 
those  places  where  milk  and  milk  products  alone  are  handled,  numbers  11,689 
visits.  The  number  of  milk  depots  is  269.  In  addition,  1,379  visits  were 
made  to  the  3,000  stores  handling  milk.  There  is  a  total  of  3,341  milk 
depots  and  stores  to  which  permits  were  granted.  107  permits  were  refused. 
153  visits  were  made  to  investigate  changes  and  alterations  and  19  for  con- 
tagious diseases. 

Two  hundred  and  sixty  visits  were  made  to  17  milk  platforms.  Within 
the  past  year  quite  a  change  has  taken  place  in  the  shipment  of  milk  into  the 
city.  Formerly  the  greater  part  of  it  came  in  over  interurban  and  steam 
railroads,  and  was  discharged  at  loading  platforms.  During  the  past  winter, 
trucks,  which  run  straight  to  the  distributor,  have  been  more  and  more 
extensively  used  until  now  it  is  estimated  that  80  per  cent  of  all  milk  comes 
in  on  trucks.  The  chief  work  that  is  done  at  the  platform  is  to  note  unwashed 
and  untagged  cans,  the  taking  of  the  temperature  of  milk  and  the  collection 
of  samples  for  examination.  Similar  samples  are  taken  of  the  milk  on  trucks 
at  their  entrance  to  the  city  or  at  least  before  they  have  discharged  their  load. 
2,205  milk  temperatures  were  taken  and  11,950  samples  collected.  These 
visits  to  the  platforms  and  the  trucks  resulted  in  the  rejection  of  1,329  gal- 
lons of  milk,  the  most  common  cause  for  rejection  being  the  shipment  from 


Public  Health  Services  149 

excluded  dairies.     Other  causes  were:    untagged  or  dirty  cans,  shipment 
from  known  tuberculosis  herds  and  selling  without  a  license. 

There  are  in  the  city  of  Cleveland  three  wholesale  ice  cream  plants,  two 
of  which,  however,  have  been  consolidated.  To  other  plants  which  produce 
ice  cream  for  their  own  retail  trade,  totaling  about  60,  3,050  visits  were  made 
during  the  year. 

There  are  seven  butter  factories  in  the  city.  To  these  seven,  forty  visits 
of  inspection  were  made. 

Four  slaughter  houses  in  the  city  of  Cleveland  are  under  inspection  by 
this  bureau,  and  eight  are  under  federal  inspection.  35  slaughter  houses 
outside  of  the  city  slaughter  on  definite  days  and  postmortem  examinations 
of  all  carcasses  are  made  before  shipment. 

In  inspection  work  before  slaughter  the  following  numbers  of  food  ani- 
mals have  come  under  the  eye  of  the  bureau:  135,317  cattle,  942,659  hogs, 
359,095  sheep,  115,377  calves.  Of  these  there  were  rejected:  1,534  cattle 
(more  than  50  per  cent  for  tuberculosis,  more  than  25  per  cent  for  actinomy- 
cosis), 471  hogs  (nearly  60  per  cent  for  cholera,  none  for  tuberculosis),  359 
sheep  (emaciation  and  crippling  the  most  prominent  causes,  actual  disease 
about  10  per  cent),  308  calves  (immaturity,  emaciation  and  crippling  the  most 
common  causes,  actual  disease  less  than  15  per  cent — 3  per  cent  for  tuber- 
culosis). 

Meat  animals  inspected  after  slaughter:  27,881  cattle,  35,303  hogs, 
48,294  sheep,  54,465  calves.  Rejections:  143  cattle  (more  than  67  per  cent 
for  tuberculosis),  249  hogs  (83  per  cent  for  cholera,  6  per  cent  for  tubercu- 
losis), 203  sheep,  58  calves.  In  addition  to  the  entire  animals  condemned 
before  and  after  slaughter,  parts  of  2,029  cattle,  2,607  hogs,  1,603  sheep  and 
142  calves  were  rejected  at  the  slaughter  houses. 

The  market  and  commission  house  confiscation  of  meat  totaled  63,822 
pounds.  There  are  approximately  1,150  meat  markets  in  Cleveland.  598 
complaints  in  regard  to  meat  markets  were  investigated  and  a  total  of  7,308 
visits  to  markets  made.  There  are  190  poultry  dressing  rooms,  to  which 
1,100  visits  were  made. 

At  all  slaughter  houses  and  most  meat  markets  sausage  is  made.  There 
are  eight,  or  fewer,  factories  making  sausages  exclusively.  The  visits  to 
sausage  factories  totaled  501. 

Arrests  for  violating  the  meat  ordinance  during  the  year  were  8,  arrests  for 
violations  of  the  milk  and  bottle  ordinance  4,  summons  to  prosecutor's  office 
5.  The  number  who  were  brought  to  trial  and  who  were  convicted  is  not 
stated. 

The  control  of  rabies  is  handled  jointly  with  the  Bureau  of  Communicable 
Disease  but  chiefly  by  the  Bureau  of  Milk  and  Dairy  Inspection.  Of  1,000 
dogs  which  were  reported  in  1919  to  have  bitten  one  or  more  human  beings 
in  Cleveland,  110  dogs  were  actually  rabid,  as  shown  by  observation,  or  the 
finding  of  Negri  bodies,  or  by  both  observation  and  examination.     196  per- 


150  Hospital  and  Health  Survey 

sons  were  bitten  by  these  dogs  and  received  Pasteur  treatment.  39  examina- 
tions were  made  in  the  laboratory  and  of  these  examinations  17,  or  43.5  per 
cent  of  the  total,  were  positive  for  rabies.  The  history  of  some  of  the  re- 
maining 22  dogs  was  so  suggestive  of  rabies  that  treatment  was  given  to  the 
persons  bitten. 

Forty-three  dogs  not  found,  either  dead  or  alive,  were  considered  rabid  on 
their  history  and  the  74  persons  bitten  by  them  were  treated.  In  addition 
to  the  dogs,  four  cats  were  found  to  be  rabid  on  examination  and  one  was 
considered  to  be  so  on  the  history.  14  persons  were  bitten  by  these  cats, 
12  by  those  with  known  rabies.  One  rabid  horse  bit  one  person,  and  rats 
were  reported  as  having  bitten  two  people. 

If  the  animal  is  found  alive  it  is  placed  under  observation;  if  killed  or 
found  dead,  its  brain  is  examined  for  the  presence  of  Negri  bodies.  Pasteur 
treatment  is  given  on  the  positive  diagnosis  of  rabies  on  either  of  the  grounds. 
If  the  animal  cannot  be  found  or  the  presence  of  Negri  bodies  cannot  be 
demonstrated,  the  circumstances  surrounding  the  biting  are  considered  and 
the  person  bitten  is  given  the  benefit  of  the  doubt  and  Pasteur  treatment  is 
offered. 

The  quality  of  supervision  of  the  slaughtering  and  sale  of  meat  appears 
to  be  excellent,  the  standards  being  those  of  the  Federal  Bureau  of  Animal 
Industry.  All  slaughter  houses  must  be  under  federal  or  city  license  and 
inspection  systems.  The  regulations  as  enforced  cover  all  the  usual  precau- 
tions and  requirements. 

Slaughter  house  and  food  factory  inspection  is  made  for  the  non-federal 
inspected  houses  in  the  city  and  the  28  outside  of  the  city.  About  25  per 
cent  of  the  city  killed  meat  is  slaughtered  in  other  than  federal  inspected 
houses.     No  uninspected  meat  is  permitted  for  sale  in  the  city. 

MILK  CONTROL 

The  handling  of  milk  control  in  Cleveland,  in  spite  of  the  up-to-date  regula- 
tions, suffers  from  several  radical  defects  in  principle  and  method  which  are 
probably  responsible  for  the  high  percentage  of  dangerously  polluted  milk 
samples  found  on  the  bacterial  counts  of  samples  examined  at  the  request  of 
the  Survey  by  the  Bureau  of  Laboratories  in  February  and  June,  1920. 

The  ordinances  do  not  cover  the  question  of  sterilization  of  containers. 
There  is  dangerous  neglect  of  this  important  point  in  the  technic  of  milk 
distribution  by  many  dealers.  Exclusion  of  milk  supplies  is  based  on  the 
condition  of  the  dairy,  and  the  results  of  inspection  of  the  premises  where 
milk  is  handled  and  pasteurized.  The  routine  use  of  bacterial  counts  is  not 
a  basis  of  milk  control. 

The  chief  of  the  bureau  agreed  that  reliance  placed  upon  inspection  of 
dairies,  the  amount  of  dirt  by  the  clarifying  test,  and  the  standard  method 
of  pasteurizing  and  recording  by  temperature  and  duration  of  exposure, 
cannot  be  relied  upon  to  guarantee  a  safe  milk  to  the  consumer  as  long  as 
unstcrilized  containers  are  used,  which  make  the  milk  unreliable  even  after 


Public  Health  Services  151 

pasteurization.     Little  attention  is  paid  to  bacteriological  counts  for  exclu- 
sion of  milk. 

At  present,  with  the  apparently  limited  force,  the  division  could  with 
advantage  gradually  change  its  policy  from  field  inspection  to  laboratory 
control  of  the  delivered  milk.  Milk  inspection  is  carried  out  in  the  country 
within  a  radius  of  200  miles  and  at  the  pasteurizing  plants  outside  and  inside 
the  city.  Chemical  tests  are  made  by  the  inspectors  themselves  at  the 
Division  of  Health  laboratory.  Bacteriological  tests  are  made  by  the  bac- 
teriological laboratory  under  the  director  of  laboratories. 

The  following  is  quoted  from  field  notes  made  by  the  investigator  for  the 
Survey  on  accompanying  a  dairy  inspector  on  his  rounds  in  the  country: 

"The  inspector  stated  that  he  covered  his  old  route  once  a  year  and  that  he  tried  to 
cover  new  territory  more  often.  During  the  winter  the  inspectors  do  very  little  work  in 
the  country  and  in  the  summer  are  often  called  out  to  do  other  work.  He  had  900  dairies 
last  year  under  his  care  and  will  have  about  1,200  this  year.  When  he  is  on  the  road  he 
sees  from  10  to  15  dairies  a  day.  Dairies  which  make  butter  do  not  have  to  come  up  to 
the  standard :  in  fact,  he  told  of  several  very  poor  dairies  to  which  he  had  suggested  that 
they  make  butter  instead  of  shipping  milk.     This  is  certainly  a  dangerous  policy. 

There  are  no  bacteriological  tests  to  determine  the  cleanliness  of  utensils.  No  search 
is  made  for  the  cause  of  a  high  bacteriological  count,  where  the  milk  is  brought  in,  with  a 
notice  to  the  inspectors  to  follow  up  the  high  counts. 

The  score  card  shows  that  more  emphasis  is  put  on  technic  than  construction.  The 
inspector  observed  really  seemed  interested  in  the  cleanliness  of  the  process,  although  he 
scored  dairies  without  seeing  the  process  of  milking  or  handling  of  milk.  The  inspector 
was  primarily  interested  in  clean  utensils  and  provisions  for  cooling.  The  emphasis  is 
evidently  correctly  placed.  The  previous  score  card  is  not  taken  with  him  when  he  goes 
to  make  a  second  inspection.     He  carries  the  facts  as  to  previous  conditions  in  his  head." 

Firmness  and  an  entirely  consistent  policy  of  exclusion  for  specified  defects  does  not 
prevail.  "Many  dairies  were  using  milking  machines,  which  are  exceedingly  dangerous 
unless  cared  for  immaculately.  Many  of  the  machines  seen  were  dirty.  They  cannot  be 
sterilized.  In  one  dairy  an  elaborate  sterilizing  plant  was  found  with  all  utensils  sterilized, 
but  12  dirty  milking  machines." 

Tables  VII.  and  VIII.  in  the  Appendix  represent  the  official  record  of 
raw  (certified)  and  pasteurized  market  milk  in  Cleveland  during  the  past 
six  years. 

The  following  reports  were  received  by  the  Survey  from  the  bacterio- 
logical laboratory  of  the  Division  of  Health : 

March    19,    1920 

"Enclosed  herewith  are  the  results  of  the  bacteriological  examinations  of  the  Cleve- 
land Milk  Supply  made  recently  for  the  Cleveland  Hospital  Survey. 

"From  these  we  have  made  the  following  notations:  There  were  103  samples  ex- 
amined. Of  those  containing  50,000  or  less  bacteria  colonies  per  c.  c.  there  were  43,  or 
41.7';.     From  51,000  to  100,000,  inclusive,  there  were  nine  samples,  or  8.7%.     Of  those 


152  Hospital  and  Health  Survey 


from  100  and  1,000  to  500,000,  inclusive,  there  were  21  samples,  or  20.3%.     30  samples, 
or  29.1%  contained  over  500,000  colonies  per  c.c. 

"The  presence  of  gas  producers  in  lactose  broth  was  found  in  52  samples,  or  50.5%. 
Six  of  these  samples  showed  the  presence  of  gas  formers  in  all  five  dilutions  and  one  of 
these  showed  the  presence  in  all  tests  of  all  dilutions.  Five  samples  showed  the  presence 
of  gas  formers  in  four  of  the  five  dilutions. 

"Of  the  92  samples  examined  in  triplicate  for  the  presence  of  spore  forming  gas  pro- 
ducers 36  samples  (39%)  gave  positive  results. 

Fermentations  Spore  Formers 

Positive   Samples    Positive  Tests  Positive    Samples  Positive  Tests 

No.            Per            No.  Per  No.            Per            No.  Per 

Colonies  per  c.c.                                                   Cent  Cent  Cent  Cent 

Under  50,000 21  50.  75  11.6  12  23.  24  21.6 

51,000  to  100,000 4  44.4  8  6.  3  33.3  4  19.1 

100,000  to  500,000 12  57.1  44  14.  5  23.8  9  15.8 

Over  500,000 16  53.3  99  22.  12  40.  29  33.3 

"The  methods  pursued  in  the  examination  of  Cleveland  Market  Milk  for  the  Hospital 
Survey  were  as  follows: 

COLLECTION  OF  SAMPLES 

"Samples  were  collected  from  the  various  milk  plants,  milk  wagons  and  grocery  stores 
by  the  writer  and  other  laboratory  employes.  The  milk  was  brought  direct  to  the  labora- 
tory in  the  original  package  and  examined  immediately.  Owing  to  the  low  temperature 
of  the  weather  the  samples  were  not  iced  in  transit.  Although  the  temperature  was  not 
taken,  it  is  safe  to  say  that  the  milk  did  not  reach  a  temperature  of  more  than  three  or 
four  degrees  above,  and  in  most  cases  was  several  degrees  below  the  temperature  at  which 
it  was  received,  by  the  time  plating  was  begun.     Both  quart  and  pint  bottles  were  collected. 

METHODS  OF  EXAMINATION 

"Agar  plates  were  made,  using  plain  standard  agar  in  triplicate  dilutions  of  1:100 
and  1:1000.  Fermentations  were  made  in  triplicate  in  lactose  broth  in  quantities  of 
10  c.c,  1  c.c,  0.1  c.c,  0.01  c.c.  and  0.001  c.c.  The  plates  were  counted  after  24  hours  incuba- 
tion at  37  degrees  C.  and  the  average  taken  for  record.  Where  the  count  was  high  it  was 
recorded  as  an  estimate;  for  example,  'Over  500,000.'  If  fermentation  occurred,  a  trans- 
plant was  made  from  the  fermentation  tube  (showing  gas)  to  eosin-methylen  blue  agar, 
the  organism  isolated  in  a  pure  culture  for  further  study.  Fermentations  incubated  for 
at  least  72  hours. 

"Triplicate  specimens  of  10  c.c  of  milk  each  were  placed  in  test  tubes  with  a  few  drops 
of  azolitmin  solution  and  heated  in  the  water  bath  at  80  degrees  C.  for  30  minutes,  and  then 
incubated  at  37  degrees  C.  for  72  hours  or  until  gas  production  was  indicated.  It  was  then 
transplanted  to  lactose  fermentation  tubes  and  reincubated,  as  a  control  on  the  presence 
of  gas  production.  These  cultures  were  then  plated  on  plain  agar  and  incubated  anaero- 
bically  for  isolation  in  pure  culture  for  further  examination. 

"This  covers  in  general  the  methods  of  procedure  with  the  Hospital  Survey  samples. 
Some  other  examinations  were  originally  planned,  but  either  the  necessary  material  and 


Public  Health  Services  153 


equipment  were  not  at  hand,  or  other  immediate  facilities  were  lacking,  so  that  the  work 
could  not  be  consistently  carried  out  and  was  therefore  discontinued." 

A  series  of  samples  examined  in  June  were  analyzed  in  a  somewhat 
more  detailed  manner,  as  shown  in  the  accompanying  report  from  the  same 
source. 

"July  8,  1920. 
"Enclosed  herewith  is  a  classified  report  of  the  bacteriological  examination  of  Cleve- 
land market  milk. 

"Bacteriological  Examination — Counts  were  made  in  duplicate  on  plain  agar  with 
dilutions  of  1:1000  in  sterile  tap  water  incubated  at  37  degrees  C.  for  24  hours.  The  aver- 
age of  the  duplicates  was  recorded.  Fermentation  tests  for  the  presence  of  gas  producers 
was  made  in  dilutions  of  1:1000,  1:100,  1:10,  1  and  10  c.c,  respectively,  in  triplicates,  using 
1  %  lactose  broth  Dunham  tubes.  The  figures  in  the  corresponding  columns  in  the  report 
indicate  the  number  of  triplicates  showing  the  presence  of  gas.  Triplicate  tests  for  spore 
bearing  gas  formers  were  made  by  placing  10  c.c.  of  milk  in  a  6-inch  test  tube  with  a  couple 
of  drops  of  sterile  azolitmin  solution,  and  heating  in  the  water  bath  at  80  degrees  C.  for  at 
least  30  minutes.  These  were  then  incubated  at  37  degrees  C.  for  72  hours  or  until  gas 
formation  was  indicated,  and  then  transferred  to  1%  lactose  broth  in  Dunham  tubes. 
The  column  "Ana,"  in  the  report  indicates  the  number  of  these  showing  the  presence  of  gas." 

CLASSIFICATION  OF  DEALERS  AND  RESULTS 

At  a  conference  with  the  four  city  dairy  inspectors  who  are  familiar  with  the  dairy 
premises  and  personnel,  the  dealers  were  placed  in  three  groups: 

Group  1 — Dealers  whose  premises,  equipment  and  methods  are  of  the 
best,  equipped  with  bottle  sterilizers,  coolers,  automatic  filler  and  capper,  etc. 

Group  2 — Those  whose  methods  may  be  satisfactory  but  who  are  not 
equipped  with  the  most  "up-to-date"  apparatus,  such  as  sterilizers,  auto- 
matic fillers,  cappers,  etc. 

Group  3 — Those  whose  premises,  equipment  and  methods  are  the  cause 
of  more  or  less  dissatisfaction. 

Classes — The  groups  are  sub-divided  into  three  classes,  according  to  the  bacterio- 
logical results. 

Class  A — Contains  those  whose  bacteria  count  does  not  exceed  50,000 
colonies  per  c.c.  nor  have  gas  formation  in  more  than  50%  of  the  fermenta- 
tion tests. 

Class  B — Includes  all  that  do  not  belong  to  Class  A,  but  which  do  not 
have  a  bacteria  count  of  over  500,000  colonies  per  c.c. 

Class  C — Includes  all  with  a  bacteria  count  of  over  500,000  colonies 
per  c.c. 

A  classification  of  the  patrons  is  suggested  by  indicating  the  so-called  better  residence 
sections  by  "X,"  the  medium  sections  by  "Y,"  and  the  poorer  sections,  factory  districts 
and  congested  portions  of  the  city  by  "Z." 


154  Hospital  and  Health  Survey 

In  Table  IX.  will  be  found  the  detailed  results  of  this  study. 

It  is  easy  to  see  froni  the  reports  that  intelligent,  consistent,  economical 
and  constructive  work  through  bacterial  counts  of  milk  is  needed  to  clean 
up  the  milk  supply  by  tracing  the  dirty  supplies  to  their  source,  by  testing 
the  pasteurized  product  as  delivered  to  the  consumer,  and  then  following 
back  to  the  production  point  to  discover  the  place  and  cause  of  the  con- 
tamination. 

Among  the  reasons  to  which  the  unsatisfactory  condition  of  the  milk 
must  be  attributed  are  the  holding  of  pasteurized  milk  without  prompt  cool- 
ing, in  the  containers  used  in  the  process  of  pasteurizing  before  bottling; 
the  use  of  unsterilized  containers  for  distribution  to  the  consumer;  the  ab- 
sence of  any  prosecution  based  on  bacteriological  tests;  and  the  emphasis 
in  prosecution  of  farmers  solely  upon  the  sediment  test  and  butter  fat  con- 
tent. The  system  of  milk  control  does  not  put  any  effective  check  by  bac- 
teriological methods  upon  the  cleanliness  of  the  milk  before  pasteurization. 
The  dealers  are  prosecuted  for  failure  to  meet  the  requirements  in  butter  fat 
and  sediment  test,  for  use  of  bottles  not  their  own,  for  the  condition  of  their 
premises  and  for  the  processes  used  in  pasteurizing  and  bottling.  The  milk 
bottle  caps  do  not  show  the  grade  or  date  or  anything  except  advertising 
and  trade  terms,  to  indicate  the  quality  and  age  of  the  milk.  An  official 
and  uniform  text  on  caps  would  better  protect  the  consumer. 

It  is  recommended  that  bacterial  count  control  largely  replace  the  present 
diffuse  and  unproductive  system  of  milk  and  dairy  inspection,  and  that  auto- 
mobile transportation  sufficient  to  save  the  time  of  field  inspectors  be  pro- 
vided. 

In  this  bureau,  as  elsewhere  in  the  Division  of  Health,  we  find  workers 
with  sufficient  knowledge  but  hampered  by  lack  of  sound  policies,  and  lack- 
ing in  the  educational  facilities  upon  which  good  preventive  health  work  is 
usually  done. 

The  staff  meets  for  conference  on  Saturday  mornings  to  discuss  policies 
and  the  service.  There  would  seem  to  be  no  good  reason  for  keeping  this 
bureau  separate  from  the  other  food  inspection  service  now  carried  on  under 
the  city  chemist. 

The  chemical  laboratory  should  not  have  inspectional  functions  but  should 
be  used  as  a  source  for  facts,  upon  which  records,  prosecutions  and  exclusion 
of  food  should  be  determined. 

The  personnel  of  the  bureau,  except  the  director,  comes  from  the  civil 
service  eligible  lists.  Applicants  have  no  medical  examination,  since  they 
are  not  eligible  for  any  pension  fund.  They  are  supposed  to  pass  a  mental 
examination  on  some  of  the  technical  information  required  in  dairy  and 
meat  inspection.  This  eligible  list  has  been  eliminated  for  the  past  two 
years  as  there  have  been  no  examinations  held  by  the  Civil  Service  Com- 
mission. Inspectors  are  taken  as  they  come,  without  examination.  They 
receive  for  the  first  year  $1,500  salary;  for  the  second  year  $1,650,  and  for 
the  third  year  $1,800;  supervising  lay  inspector  $2,000;  the  two  assistants 
$2,400;    and  the  chief  $3,800. 


Public  Health  Services  155 


Bureau  of  Laboratories 

THE  work  of  the  Bureau  of  Laboratories  is  carried  on  under  the  super- 
vision of  the  Chief  of  the  Bureau,  known  as  the  Director  of  Laboratories, 
at  present  a  part-time  employe,  also  occupying  the  chair  of  bacteriology 
and  hygiene  at  Western  Reserve  University  Medical  School.  Two  laborator- 
ies are  maintained,  one  the  bacteriological  laboratory  for  the  examination  of 
cultures,  smears,  blood  specimens  and  pathological  specimens  for  the  diag- 
nosis of  disease,  and  the  examination  of  water,  milk  and  other  substances  for 
their  safety  and  purity  as  foods.  The  second  laboratory  is  a  chemical  labora- 
tory and  is  charged  with  the  analysis  of  food  and  drugs,  the  sanitary  super- 
vision of  stores,  restaurants,  bake  shops  and  the  like. 

The  ordinance  authorizing  the  bureau  provides  that  the  function  of  the 
laboratory  shall  be  to  assist  in  the  diagnosis  of  communicable  disease,  to  fix 
the  period  of  quarantine,  to  determine  the  quality  of  the  milk,  food  and  water 
supply  of  Cleveland,  and  to  perform  such  chemical  and  bacteriological 
analyses  as  are  related  to  public  welfare. 

The  functions  of  the  laboratories  are  similar  to  those  of  other  municipal 
health  laboratories:  i.  e.,  diagnosis,  analysis,  production,  research.  The  out- 
fits supplied  for  diagnostic  uses  are  assembled  but  not  manufactured  at  the 
laboratory  and  there  are  no  biological  products  produced  as  a  routine  by  the 
city. 

The  Chief  of  the  Bureau  of  Laboratories,  under  the  direction  of  the  Com- 
missioner of  Health,  has  charge  of  all  employes  of  the  bureau,  assigns  their 
duties  and  enforces  the  laws  relating  to  the  functions  of  the  bureau. 

The  bureau  supplies  outfits  for  the  collection  of  material  from  suspected 
cases  of  diphtheria,  typhoid  fever,  tuberculosis,  rabies,  and  such  other  com- 
municable diseases  as  the  Commissioner  of  Health  and  the  Chief  of  the 
Bureau  of  Communicable  Diseases  may  decide. 

No  diagnostic  services  are  provided  for  meningococcus  or  other  organisms 
causing  meningitis  or  for  pathological  changes  in  the  spinal  fluid.  No  type 
determinations  are  offered  for  pneumococcus  or  meningococcus.  No  tetanus 
antitoxin,  antipneumococcus  vaccine  or  antimeningococcus  serum  are  avail- 
able through  the  laboratory  or  any  bureau  of  the  Division  of  Health.  Viru- 
lence tests  for  persistent  diphtheria  carrier  organisms  are  rarely  made  (in  per- 
haps 10  to  12  cases  a  year)  and  then  by  the  lethal  test  instead  of  by  the  more 
economical  and  quite  as  reliable  intradermal  test  in  guinea  pigs. 

The  bureau  examines  and  reports  on  samples  of  milk  and  dairy  products 
submitted  by  the  Bureau  of  Food  and  Dairy  Inspection,  and  such  samples 
from  other  sources  as  may  be  approved  by  the  Commissioner  and  the  Chief  of 
the  Bureau  of  Laboratories. 

The  laboratory's  activities  in  milk  examinations  were  as  follows: 

There  were  12,245  milk  samples  examined;  10,016  shipper's  samples  and 
2,229  dealer's  samples.     Four  per  cent  of  all  were  below  the  lactometer 


156  Hospital  and  Health  Survey 

standard;  5.5  per  cent  below  the  fat  standard;  27.5  per  cent  below  the  total 
solid  standard  and  19.7  per  cent  below  the  standard  of  cleanliness  by  the  sedi- 
ment test. 

When  shipper's  samples  are  found  to  fall  below  the  legal  standards, 
written  notices  are  sent  to  the  producer  calling  his  attention  to  these  facts. 
Later,  averaging  perhaps  two  months  from  the  time  the  notice  was  first  sent, 
an  effort  is  made  to  secure  samples  of  milk  from  the  same  producer  to  see 
whether  or  not  the  fault  complained  of  has  been  corrected.  This  is  poor 
follow-up  and  leaves  too  much  to  chance  and  the  good  will  of  the  shipper. 

No  bacterial  counts  were  made  of  the  shipper's  samples  of  milk,  but  it  is 
stated  that  50  per  cent  of  the  dealer's  samples  had  more  than  50,000  bac- 
teria to  the  c.  c.  (It  should  be  remembered  that  the  milk  ordinance  speci- 
fies 500,000  as  the  bacterial  standard  for  milk  which  may  be  sold  in  the  city 
of  Cleveland.) 

The  bureau  makes  chemical  and  bacteriological  examinations  of  the 
municipal  water  supply  (including  samples  from  springs  in  parks)  at  approved 
intervals,  as  well  as  sanitary  examinations  of  water  used  by  citizens  of  Cleve- 
land at  their  homes  in  the  city  or  country.  It  also  examines  from  time  to 
time  such  water  as  is  offered  for  sale.  The  bureau  makes  such  chemical, 
bacteriological  and  pathological  examinations  of  samples  of  foods  submitted 
by  the  Bureau  of  Food  and  Dairy  Inspection  as  may  be  necessary.  It  makes 
tests  as  to  the  bactericidal  efficiency  of  disinfectants  and  germicides. 

The  work  of  the  bacteriological  laboratory  is  carried  on  by  a  staff  con- 
sisting of  a  director  on  part-time,  and  four  other  persons,  two  of  whom  are 
listed  as  bacteriologists,  one  as  a  physician,  the  other  as  serologist.  One  of 
the  four  named  above  has,  under  the  director  of  the  bureau,  general  super- 
vision of  the  laboratory.  There  are  four  laboratory  assistants,  one  who 
cleans  glassware,  being  classified  as  laborer,  one  messenger  and  two  typists 
as  clerical  assistants. 

The  following  summary  of  the  work  of  the  bacteriological  laboratory  indi- 
cates the  types  of  examinations  made  and  their  number  in  1919.  45,711 
specimens  were  examined,  an  increase  of  more  than  50  per  cent  over  the  num- 
ber examined  in  the  previous  year.  Specimens  of  sputum,  blood  for  Widal 
tests  and  the  heads  of  animals  for  the  diagnosis  of  rabies,  showed  a  decrease 
in  number.  The  decided  increase  in  total  specimens  was  due  to  an  83  per 
cent  increase  in  throat  cultures  and  the  increase  in  the  number  of  blood 
specimens  sent  in  for  Wassermann  tests  and  of  smears  for  gonococcus.  Diph- 
theria having  shown  a  low  incidence  in  the  three  years  previous  to  1919, 
became  more  prevalent  during  that  year,  and  this  increased  prevalence 
accounts  largely  for  the  increased  number  of  cultures.  It  is  not  unlikely, 
however,  that  more  exposure  cultures  were  taken  than  has  been  usual  in  the 
past  since  this  procedure  was  made  very  extensive  whenever  diphtheria  oc- 
curred in  schools  or  institutions.  The  probable  truth  of  this  inference  is 
indicated  by  the  fact  that  while  diagnosis  cultures  increased  66  per  cent, 
exposure  cultures  more  than  doubled  in  number.  There  was  a  diminution 
in  sputum  specimens  from  3,216  in  1918  to  3,101  in  1919,  and  from  764  in 
which  the  tubercle  bacillus  was  found  in  1918,  to  630  in  1919. 


Public  Health  Services  157 

Increasing  interest  in  venereal  disease  control  may  well  explain  the  in- 
creased number  of  examinations  for  their  diagnosis.  Wassermann  speci- 
mens presented  for  examination  increased  from  5,807  in  1918  to  8,070  in 
1919  and  the  positive  findings  from  1,498  to  2,658. 

An  approximate  estimate  of  the  cost  per  specimen  is  33  cents  for  all 
diagnostic  tests. 

The  chief  criticisms  of  the  laboratory  which  have  been  heard  relate  to  the 
dependability  of  its  reports  in  laboratory  diagnoses  and  upon  the  maintenance 
at  the  distributing  stations  of  a  proper  supply  of  outfits  for  the  collection  of 
material  for  diagnosis,  and  of  diphtheria  antitoxin  for  use  in  immunization 
and  treatment  of  diphtheria  patients  and  those  exposed  to  diphtheria. 

In  general,  according  to  the  judgment  of  physicians  having  experience  in 
this  matter,  it  appears  that  the  Wassermann  work  of  the  city  laboratory  is 
of  high  character.  A  similar  statement  would  undoubtedly  be  made  of  the 
morphological  differentiation  of  the  pseudo-forms  from  the  true  forms  of  the 
diphtheria  bacillus.  In  diphtheria  particularly  it  is  probably  true  that  a 
doubtful  specimen  is  rarely  passed  as  positive  or  negative  on  the  judgment 
of  any  one  person;  it  is  the  rule  of  the  laboratory  that  such  specimens  shall 
always  be  seen  and  confirmed  by  more  than  one  bacteriologist. 


Collection  of  Specimens  for  Diagnosis 

The  main  distributing  stations  for  outfits  of  all  kinds  and  for  diphtheria 
antitoxin  are  the  police  stations  of  the  city;  a  few  of  the  larger  drug  stores  as 
well,  have  these  supplies  for  the  convenience  of  physicians  in  the  downtown 
office  buildings.  In  each  police  station  a  small  incubator  heated  by  an  elec- 
tric lamp  is  to  be  found,  and  the  physician,  after  making  a  culture,  is  thus 
enabled  to  get  it  promptly  under  a  suitable  temperature,  so  that  when  taken 
to  the  laboratory  it  is  usually  ready  for  immediate  examination.  Last  sum- 
mer a  number  of  these  incubators  were  out  of  order  for  some  time  through  a 
difficulty  experienced  in  getting  the  lamps.  This  difficulty  was  corrected 
before  the  cooler  weather  set  in  last  fall. 

Frequent  criticisms  are  received  of  the  failure  to  find  outfits  or  anti- 
toxin in  these  stations  and  of  the  bad  condition  of  these  outfits.  Much,  but 
not  all,  of  this  difficulty  is  avoided  when  the  laboratory  has  a  reliable  mes- 
senger, but  the  man  who  can  qualify  as  such  usually  soon  finds  a  better 
paying  job  and  leaves  the  city's  employ.  He  collects  daily  from  each  sta- 
tion and  is  supposed  to  assure  himself  at  each  visit  that  an  adequate  supply 
of  outfits  in  perfect  condition  and  a  sufficient  supply  of  antitoxin  are  on  hand 
and  that  the  incubator  is  operating  properly.  ^^L^ 

One  cause  of  the  difficulties  met  in  keeping  the  stations  properly  supplied 
is  the  fact  that  physicians  at  times  take  more  Outfits  or  more  antitoxin  than 
they  need  for  immediate  use,  leaving  nothing  for  those  who  may  follow. 
Further,  it  is  quite  certainly  known  that  Cleveland  antitoxin  is  occasionally 
used  for  patients  who  are  not  residents  of  Cleveland  but  of  the  suburbs. 


158  Hospital  and  Health  Survey 

Twelve  of  the  police  precinct  stations  were  visited  by  our  investigator 
with  the  collector  on  one  of  his  routine  collecting  trips.  This  collector  had 
been  in  the  service  for  six  months.  He  has  a  good  Ford  car  at  his  disposal 
and  makes  a  daily  trip  covering  all  the  police  stations,  beginning  at  6  a.  m. 
and  finishing  about  10  a.  m.  Three  times  a  week  he  also  includes  the  health 
centers.  On  Sunday  each  police  precinct  is  telephoned,  and  visits  are  made 
only  where  there  is  material  to  be  collected.  In  the  afternoon  his  work  con- 
sists of  answering  telephone  orders,  getting  supplies  from  bath  houses,  ice 
wagons,  etc.,  and  also  doing  odd  jobs  around  the  laboratory.  He  is  supposed 
to  keep  the  police  stations  supplied  with  the  following:  4  to  8  diphtheria 
culture  tubes,  6  to  10  sputum  bottles,  antitoxin  in  units  of  1,000,  5,000  and 
10,000,  about  4  or  5  each;  6  to  8  Wassermann  outfits,  Neisser  outfits,  where 
there  is  demand,  and  Widal  outfits. 

Each  precinct  has  an  electric  incubator.  Diphtheria  cultures  are  sup- 
posed to  be  kept  in  this;  sputum  and  Wassermann  outside.  Sometimes 
mistakes  are  made,  and  occasionally  the  doors  are  left  open.  Supplies  in 
some  stations  are  kept  in  cupboards  which  are  unlocked.  No  supplies  are 
kept  on  ice.  It  is  impossible  to  ascertain  how  long  supplies  are  kept  with- 
out replacement.  The  collector  says  that  he  has  instructions  to  examine 
the  diphtheria  culture  tubes  at  least  every  week  and  bring  in  all  defective 
media. 

"Police  Precinct  No.  2 — No  material  to  be  collected.  Supplies  kept  in  a  locked 
closet.  Material  on  hand:  four  diphtheria;  ten  Widal ;  three  Wassermann ;  three  sputum ; 
four  antitoxin,  two  each  1,000  and  5,000,  no  10,000  units. 

"Police  Precinct  No.  3 — Material  collected:  two  Wassermann,  one  Neisser,  one 
diphtheria.  Material  kept  in  locked  closet.  Material  on  hand:  four  diphtheria;  one 
Wassermann;  eleven  sputum;  seven  Widal;  antitoxin,  no  5,000,  two  10,000,  four  1,000  units. 

"Police  Precinct  No.  4 — Material  collected:  one  sputum,  one  Wassermann,  three 
diphtheria.  Material  kept  in  closet  without  lock.  Material  on  hand:  one  diphtheria; 
six  antitoxin,  two  of  which  were  5,000,  four  10,000  and  no  1,000  units;  three  sputum; 
nine  Widal. 

"Police  Precinct  No.  5 — Material  collected:  one  Wassermann,  one  diphtheria,  one 
sputum.  Supplies  kept  in  closet  without  a  lock.  Material  on  hand:  seven  diphtheria; 
seven  Wassermann;  eight  Widal;  five  sputum;  antitoxin,  three  5,000,  two  1,000  and  four 
10,000  units. 

"Police  Precinct  No.  6 — Material  collected:  two  Neisser,  one  Wassermann,  five 
diphtheria.  Material  kept  in  cupboard  without  a  lock.  Material  on  hand:  three  diph- 
theria; six  Wassermann;  three  sputum;   antitoxin,  three  5,000,  one  10,000,  five  1,000  units. 

"Police  Precinct  No.  7 — Material  collected:  none.  Supplies  kept  in  safe.  Material 
on  hand:  eight  diphtheria;  four  Wassermann;  five  typhoid;  antitoxin,  five  1,000,  no  5,000 
or  10,000  units. 

"Police  Precinct  No.  9 — Material  collected:  three  diphtheria,  one  sputum  Sup- 
plies kept  in  a  closet  with  no  lock.  Material  on  hand:  nine  diphtheria  tubes,  two  of  which 
were  dry;    nine  antitoxin;  nine  sputum;  eight  Widal;  twelve  Wassermann  outfits. 


Public  Health  Services  159 


"Police  Precinct  No.  10 — Material  collected:  one  sputum,  two  diphtheria.  Sup- 
plies kept  in  locked  cupboard.  Material  on  hand:  five  diphtheria  cultures,  two  of  which 
were  dry ;  thirteen  antitoxin ;  eight  Neisser ;  nine  Widal ;  three  Wassermann ;  two  sputum 
outfits. 

"Police  Precinct  No.  11 — Material  collected:  three  Wassermann,  five  diphtheria, 
three  sputum.  Supplies  kept  in  closet  without  lock.  Material  on  hand:  one  diphtheria; 
thirteen  antitoxin,  three  1,000,  four  5,000,  six  10,000;  seven  sputum ;  six  Wassermann ;  five 
Widal  outfits. 

"Police  Precinct  No.  12 — Nothing  to  collect.  Supplies  kept  in  office  in  unlocked 
cupboard.  Material  on  hand:  seven  diphtheria  cultures,  two  of  which  were  dry;  eleven 
antitoxin;  three  sputum;  one  dozen  Widal;  one  dozen  Wassermann. 

"Police  Precinct  No.  13 — Material  collected:  three  diphtheria,  six  Wassermann,  one 
sputum.  Material  kept  in  closet  with  no  lock.  Material  on  hand:  no  diphtheria;  two 
Wassermanu;  three  sputum;  two  antitoxin,  one  each  1,000  and  10,000;  three  typhoid ;  one 
Neisser  outfit. 

"Police  Precinct  No.  14 — Material  collected:  one  sputum,  one  diphtheria.  Sup- 
plies kept  in  a  closet  without  a  lock.  Material  on  hand:  three  diphtheria;  five  Wassermann, 
ten  antitoxin,  three  1,000,  three  5,000  and  four  10,000;    three  sputum;  two  Widal  outfits. 

"The  police  captains  and  lieutenants  said  that  they  had  had  a  great  many  complaints 
because  of  lack  of  material  and  also  because  the  diphtheria  culture  material  was  not  in 
good  shape. 

"There  have  been  a  great  many  recent  complaints  because  the  Wassermann  outfits  do 
not  now  include  a  needle.  The  collector  explained  the  complaints  about  lack  of  material 
by  saying  that  recently  the  department  shipments  of  antitoxin  and  diphtheria  culture 
material  had  been  delayed  by  freight  strikes,  etc  ,  and  that  for  some  time  they  had  prac- 
tically no  material  on  hand. 

"The  collector  appeared  to  be  intelligent,  alert  and  interested  in  his  job  and  could  im- 
prove the  service  if  not  hampered  by  lack  of  supplies  at  the  central  office." 

Ever  since  it  began  its  work  the  laboratory  has  interested  itself  particu- 
larly in  the  water  supply  of  the  city.  The  amount  of  chlorine  used  from  day 
to  day  is  based  mainly  upon  bacteriological  examinations  of  the  water  and 
these  are  now  made  by  the  Division  of  Water  under  the  Department  of 
Public  Service.  The  continuance  of  the  examinations  by  the  bacteriological 
laboratory  constitute,  however,  a  valuable  check  upon  those  of  the  division 
directly  responsible. 

As  a  summary  of  the  results  of  the  examinations  of  the  city  water  for  the 
year  1919  in  the  bacteriological  laboratory  it  may  be  said  first,  that  the  raw 
water  shows  great  pollution;  second,  that  the  chlorinated  water  shows  con- 
siderable variation,  that  it  is  apt  to  be  fairly  or  entirely  free  from  evidences 
of  pollution  in  the  summer  and  winter,  while  in  the  spring  and  fall,  particu- 
larly the  former,  it  shows  traces  of  pollution  varying  from  slight  to  decided 
in  a  month;  third,  that  the  blend  of ■  filtered  chlorinated  and  unfiltered 
chlorinated  water,  as  used  on  the  East  Side  of  the  city,  shows  some  improve- 
ment over  the  chlorinated  water  previously  in  use;  fourth,  occasional  colon 
colonies  are  found  in  the  filtered  chlorinated  water. 


160  Hospital  and  Health  Survey 

The  work  of  the  chemical  laboratory  under  the  director  of  the  bureau  is 
performed  by  a  staff  consisting  of  three  chemists,  one  a  chief  chemist  who 
supervises  the  work  of  the  bureau  and  performs  some  slight  services  for  the 
medical  school  in  demonstrating  points  of  sanitary  interest  in  the  city  to 
medical  students;  six  assistant  chemists,  six  sanitary  officers  assigned  to 
the  laboratory,  and  two  typists.  The  laboratory  has  charge  of  all  food, 
drug  and  liquor  analyses,  miscellaneous  chemical  analyses,  the  inspection  of 
drug  stores  and  of  stores,  restaurants  and  other  places  where  food,  except 
milk  or  meat,  are  produced,  sold  or  stored.  One  out  of  the  seven  chemists 
in  this  laboratory  obtained  his  position  as  a  result  of  competitive  civil  service 
examination.     The  last  examination  was  held  in  1917. 

The  Bureau  of  Food  and  Dairy  Inspection  is  charged  with  the  control  of 
the  milk  and  meat  supply  of  the  city  of  Cleveland  and  this  responsibility 
extends  from  production  to  delivery  to  the  ultimate  consumer.  The  con- 
trol of  all  other  food  is  lodged  in  the  chemical  laboratory  of  the  Bureau  of 
Laboratories.  Here,  again,  the  bureau  is  charged  with  the  sanitary  super- 
vision of  the  production,  storage  and  sale  of  these  products.  All  stores 
handling  food,  except  those  which  limit  themselves  to  the  sale  of  milk  or 
meat,  and  all  bakeries,  confectionery  stores,  groceries,  restaurants,  bottling 
works  and  the  like  are  under  their  supervision.  The  state  permits  for  res- 
taurants, etc.,  are  issued  only  after  inspection  and  approval  by  the  city  chemist 
as  to  methods  and  equipment. 

Much  attention  has  been  paid  in  the  past  to  the  sanitary  condition  of 
bakeries  and  by  cooperation  with  the  local  organizations  maintained  by 
bakeries  the  conditions  in  the  bake-shops  have  become  quite  satisfactory. 
Recently  more  attention  has  been  paid  to  the  proper  distribution  of  the 
products  of  these  shops  to  stores  and  the  care  with  which  they  are  handled 
at  these  places. 

The  inspection  work  of  the  chemical  laboratory  is  performed  by  sanitary 
patrolmen  assigned  to  the  laboratory.  During  the  year  1918  five  sanitary 
patrolmen  and  three  inspectors  were  so  assigned.  The  positions  of  inspec- 
tors were  abolished  in  the  year  1919  and  six  patrolmen  were  assigned  to  this 
duty.  The  total  number  of  inspections  are  represented  by  the  following 
figures:  inspections,  7,552;  reinspections,  7,801;  warning  letters,  340;  sum- 
mons before  the  police  prosecutor,  382;  stores  closed,  54;  arrests,  15;  con- 
victions, 13;  and  cases  pending  on  appeal  by  the  city,  2. 

No  case  is  brought  into  court  unless  all  other  means  have  been  exhausted. 
Food  stores  are  inspected  about  six  times  a  year,  bakeries  and  restaurants 
three  to  four  times  a  year;  candy  factories  about  three  times  a  year;  bottling 
establishments  according  to  season.  This  laboratory  also  does  work  for  the 
State  Medical  Board  for  violations  of  the  medical  practice  act  and  for  the 
State  Board  of  Pharmacy  and  for  the  Engineers  Board  of  the  city  (who 
provide  one  chemist  and  an  assistant  for  the  laboratory)  and  for  the  Depart- 
ment of  Public  Service. 

From  an  inspection  of  the  small  restaurants  and  food  stores  made  by  an 
investigator  for  the  Survey,  it  is  obvious  that  there  are  constant  violations 
of  ordinary  sanitary  decency  in  these  places,  which  could  be  checked  if  more 


Public  Health  Services  161 

time  were  spent  on  actual  inspection,  and  less  of  the  appropriation  for  this 
division  were  used  in  doing  non-health  work.  The  six  inspectors,  of  whom 
one  works  always  at  the  railroad  terminals,  cover  the  entire  city  and  spend  a 
large  part  of  their  time  in  traveling  from  place  to  place  in  the  city.  Good 
administration  would  suggest  that  the  sanitary  inspection  force  be  combined 
instead  of  being  split  into  the  three  groups,  so  that  each  patrolman  would 
have  a  small  district  within  which  he  would  fulfill  the  functions  of  sanitary 
inspector,  food  and  drug  inspector  and  quarantine  officer.  At  present  the 
minimum  of  actual  service  in  the  field  for  the  maximum  expense  is  accom- 
plished. 

The  Bureau  of  Laboratories  cooperates  with  other  departments  of  the  city 
government  in  inspection  work  of  all  descriptions,  with  reference  to  bacterio- 
logical and  chemical  standards.  The  bacteriological  laboratory  makes  any 
examination  of  milk  and  meat  that  comes  within  its  province,  for  the  Bureau 
of  Food  and  Dairy  Inspections.  The  chemical  laboratory  does  the  same, 
and  in  addition  examines  chemically,  food  products  other  than  milk  and  meat 
for  their  identity  and  sanitary  condition.  In  the  past  many  samples  have 
been  taken  from  retail  stores,  but  recently  much  effort  has  been  made  to  secure 
samples  of  food  as  it  enters  the  city  in  carload  lots  or  smaller  shipments,  and 
to  determine  its  quality  before  it  has  left  the  jobber.  The  laboratory  works 
in  close  cooperation  with  the  Bureau  of  Chemistry  of  the  United  States 
Department  of  Agriculture  in  this  matter. 

As  a  result  of  this  work  in  1919  four  warning  letters  were  sent;  there 
were  26  summons  to  appear  before  the  police  prosecutor,  14  arrests,  9  con- 
victions, 4  cases  discharged  and  one  case  pending  on  the  appeal  of  the  de- 
fendant: 

One  hundred  and  twenty-nine  car  lot  shipments  and  355  less  than  car  lot 
shipments  were  inspected.  The  confiscations  cover  such  articles  as  baked 
goods,  baking  powder,  cereals,  candy,  fruits,  nuts,  olives  and  pickles.  A 
considerable  number  of  fruits  and  vegetables  were  ordered  sorted. 

The  inspection  of  drug  stores  is  a  function  of  the  chemical  laboratory. 
A  special  duty  has  been  placed  upon  the  inspector  of  drug  stores  by  the 
narcotic  ordinance  of  the  city. 

The  Division  of  Health  some  years  ago  established  close  relations  with  the 
Druggists'  Association  of  Cleveland  and  through  the  cooperation  thus  at- 
tained has  been  able  to  secure  the  voluntary  removal  of  a  considerable 
number  of  the  more  objectionable  types  of  patent  medicines  from  the  shelves 
of  Cleveland  druggists. 

Aside  from  patent  medicines  and  narcotics  the  laboratory  has  been 
especially  interested  in  fraudulent  or  adulterated  preparations  and  has  suc- 
ceeded in  keeping  from  sale  a  considerable  number  and  variety  of  drugs  of 
a  type  similar  to  aspirin  and  phenacetin  which  were  misbranded  or  adulter- 
ated. 

THE   "PATENT  MEDICINE"  IN  CLEVELAND 

This  is  a  subject  that  must  be  approached  in  a  tactful  manner  because 
of  the  large  amount  of  capital  invested  in  the  manufacture  and  sale  of  these 


162  Hospital,  and  Health  Survey 


substances,    and   likewise   because   many  individuals  of  more  than  average 
intelligence  believe  in  patent  medicines  and  practise  self -medication. 

It  is  not  true  that  these  remedies  are  used  only  by  the  foreigners  and  the 
ignorant.  To  pass  over  this  subject  without  mentioning  it  would  be  to 
overlook  a  very  important  item  affecting  public  health. 

The  United  States  Government  report  shows  about  $90,000,000  to  be 
invested  in  the  production  of  proprietary  remedies.  It  does  not  classify 
these  remedies  to  show  which  ones  are  entirely  non-secret  in  nature,  stating 
their  entire  formula  on  the  label,  or  in  an  otherwise  public  manner.  It 
does  not  say  which  ones  are  based  upon  preparations  whose  formulas  are 
incorporated  in  the  United  States  Pharmacopoeia  and  National  Formulary. 
It  does  not  say  which  ones  are  mainly  alcoholic  in  nature.  It  does  not  say 
which  ones  are  entirely  secret  in  their  composition,  nor  does  it  say  how 
many  may  be  entirely  "rank  fakes."  A  need  for  such  a  classification  cer- 
tainly exists.  In  this  enlightened  age  no  one  should  be  permitted  to  buy 
anv  combination  of  drugs  upon  the  open  market  labeled  merely  as  a  "cure- 
all." 

The  discussion  of  this  subject  is  often  avoided  by  those  who  should  dis- 
cuss it,  for  fear  of  controversy  with  those  interested  in  the  business. 

These  remedies  are  manufactured  on  their  own  account  by  large  pharma- 
ceutical houses,  and  are  put  up  under  fancy  proprietary  names,  but  often 
carrying  the  full  formula  on  the  label  or  in  accompanying  literature.  These 
same  houses  also  have  what  they  call  their  private  formula  department 
where  they  fill  formulae  submitted  to  them  by  physicians,  by  combinations 
of  physicians  and  laity,  and  by  druggists  or  by  people  who  think  they  have 
a  formula  that  is  the  only  specific  for  a  certain  disease.  These  remedies  are 
also  made  by  small  concerns  who  do  only  a  "private  formula"  business. 
Again  they  are  made  in  a  small  way  by  druggists  or,  indeed,  contrary  to  the 
idea  of  the  statutes,  by  persons  whose  knowledge  of  drugs  and  medicines  is 
absolutely  nil.  They  are  likewise  made  and  offered  to  the  public  under  coined 
names  that  sound  to  the  uninitated  like  the  names  of  drugs  or  chemicals. 
In  this  way  the  public  is  advised  to  treat  a  certain  malady  by  mixing  this 
drug  with  something  well  known,  such  as  glycerin,  alcohol,  etc.,  and  then 
by  using  it  in  a  specified  manner.  These  are  usually  advertised  as  prescrip- 
tions or  in  answer  to  letters  or  supposed  letters  to  the  firm  asking  for  medical 
advice. 

Distribution  and  Sale 

The  non-secret  proprietaries  are  sold  by  agents  of  pharmaceutical  houses 
who  rail  directly  upon  physicians  and  hospitals.  Other  non-secret  remedies 
are  found  in  the  drug  stores  and  purport  to  be  the  "Best  Ever"  line  of  reme- 
dies, or  some  similar  line,  and  whose  formulae  are  usually  on  the  bottle  or 
are  given  directly  to  the  druggist. 

Among  the  secret  and  semi-secret  remedies  are  those  most  often  adver- 
tised.      The  demand  is  created  entirely  by  newspaper  advertising,  or  by  maga- 


Public  Health  Services  163 

zines,  periodicals,  calendars,  almanacs  and  other  literature  placed  directly 
in  the  hands  of  the  public.  They  are  then  sold  by  the  druggist  or  by  the 
mail  house. 

Others  are  made  and  sold  by  wagon  vendors  or  by  house-to-house  can- 
vassers who  take  orders  and  deliver  or  sell  direct.  One  method  of  the  house- 
to-house  canvasser  is  to  represent  that  the  profit,  or  part  of  it,  goes  to  a 
hospital  for  children,  thus  trying  to  sell  the  remedy  on  a  sympathy  basis. 
Many  are  sold  in  grocery  stores,  general  stores,  restaurants,  barber  shops  and 
by  anyone  who  can  create  a  volume  of  sales  satisfactory  to  the  manufacturer. 
The  drug  store  is  supposed  to  sell  the  major  portion  of  them  because  it  is  in 
a  fixed  place  of  business,  although  it  is  very  doubtful  if  the  drug  store  handles 
fifty  per  cent  of  the  proprietary  remedies  sold. 

The  newspaper  advertising  which  creates  the  demand  is  the  most  potent 
factor  in  the  distribution  of  these  remedies.  The  manufacturer  prefers  the 
names  "package  remedies,"  "home  remedies,"  "proprietary  remedies,"  and, 
of  course,  abhors  the  epithets  "fake"  and  "patents." 

One  feature  that  must  not  be  overlooked  is  the  form  of  counter  prescrib- 
ing in  some  drug  stores,  happily  few  of  them,  where  the  unsuspecting  victim 
asks  for  a  remedy  and  has  a  well  known  proprietary,  such  as  "Mother's 
Friend,"  transferred  to  a  plain  bottle  and  sold  for  $10. 

The  law  does  not  limit  the  price  to  be  charged,  nor  does  it  limit  the  sale 
to  any  set  of  responsible  and  trained  hands.  All  the  law  says  is  that  the 
label  must  not  claim  to  cure,  nor  may  it  carry  false  and  fraudulent  claims 
nor  may  the  medicine  contain  certain  harmful  drugs.  The  Pure  Food  and 
Drugs  Act  only  applies  to  the  above,  when  these  remedies  enter  interstate 
commerce. 

Situation  in  Cleveland 

Important  steps  have  been  taken  to  purify  the- traffic,  but  these  steps 
have  only  scratched  the  surface. 

Here  the  Northern  Ohio  Druggists'  Association  has  appointed  an  Ad- 
visory Board  who,  with  certain  members  of  the  Medical  and  Pharmacy 
School  faculties,  meet  from  time  to  time  with  the  city  chemist  and  pass  upon 
the  legitimacy  of  a  proprietary  remedy  in  so  far  as  existing  law  permits 
action  to  be  taken. 

The  druggists  have  also  agreed  that  any  new  "proprietary"  must  pass 
the  city  chemist  as  to  label  and  claims  before  they  will  stock  it.  In  this 
way  a  large  number  of  new  preparations  have  been  excluded  from  the  market, 
many  on  the  market  have  been  removed  and  many  labels  and  much  litera- 
ture have  been  revised. 

Some  little  cooperation  has  been  had  from  newspapers  relative  to  the 
changing  of  form  of  advertisement.  It  is  needless  to  state  that  a  newspaper 
always  endeavors  to  protect  its  advertisers  against  steps  that  tend  to  injure 
distribution  of  their  wares. 


164  Hospital  and  Health  Survey 

During  the  past  three  years  there  have  been  about  two  dozen  patent 
medicines  excluded  from  sale  in  Cleveland  and  about  three  dozen  the  claims 
of  which  have  been  modified  under  pressure  or  threat  from  this  division. 
Revision  of  labels  is  required  in  many  cases.  A  misbranding  order  is  held 
as  a  threat  over  those  who  resist  demand  for  toning  down  their  advertise- 
ments. 

On  looking  over  the  files  and  correspondence  on  fraudulent  patent  medi- 
cine claims,  it  was  found  that  the  standards  of  the  Bureau  of  Chemistry  at 
Washington  are  followed,  but  that  an  amazing  patience  and  tolerance  is 
displayed  in  dealing  with  mischievous  and  frankly  misleading  advertising 
claims.  Correspondence  in  one  flagrant  case  of  misbranding  continued  for 
twelve  months  before  any  result  was  obtained.  This  brings  discredit  on 
public  law  and  service.  The  city  chemist  has  apparently  found  it  necessary 
to  abate  his  efforts  when  he  finds  the  newspapers  of  the  city  objecting  to  the 
reduction  of  income  which  the  withdrawal  of  false  advertising  claims  of 
proprietary  remedies  incurs. 

RECOMMENDA  TIONS 

That  a  committee  of  physicians,  hospital  men,  druggists,  the  City  Health  Commissioner, 
the  City  Chemist,  the  Cleveland  Advertising  Club,  and  newspaper  men,  with  a  representa- 
tive from  the  Chamber  of  Commerce  or  other  Civic  body,  study  the  question  of  newspaper 
advertising  of  medicines  to  determine  if  it  is  essential  to  the  success:  of  the  newspaper  adver- 
tising department;  if  not,  to  recommend  it  be  discontinued;  if  it  is,  find  some  manner 
of  furnishing  the  same  space  to  the  newspaper  for  the  advertising  of  real  commodities. 
It  cannot  be  conceded  that  any  drug  should  be  advertised  to  the  public.  The  opinion  that 
anyone  may  select  his  own  treatment  of  disease  after  reading  an  advertisement  is  only 
based  upon  monetary  gain,  either  directly  or  indirectly,  and  this  factor  should  be  consid- 
ered secondary  in  dealing  with  the  protection  of  public  health. 

It  is  recommended  that  the  same  committee,  or  a  similar  one,  take  steps  to  draft 
such  city  or  state  legislation  as  will  place  the  dispensing  of  all  medicines  in  the  hands  of 
those  qualified  to  do  so,  and  with  such  safeguards  that  the  unscrupulous  ones  may  be 
reached;  (as,  for  instance,  Regulation  10  of  the  Sanitary  Code  of  the  Village  of  Athens, 
New  York,  which  forbids  the  sale  of  medicines  or  medical  appliances  otherwise  than  by 
licensed  pharmacists  or  by  physicians,  without  the  approval  of  the  health  officer;)  or  a  re- 
quirement that  all  medicines  not  issued  on  physician's  prescriptions  be  rgistered  with  the 
names  and  amounts  of  physiologically  active  ingredients,  upon  which  claims  of  therapeutic 
results  are  based,  and  a  copy  of  all  text  used  in  advertising. 

It  is  recommended  that  if  any  such  ordinance  or  regulation  is  passed,  it  be  made  ap- 
plicable at  first  and  enforced  only  within  the  city  of  Cleveland,  and  later  that  an  attempt 
be  made  to  have  the  matter  adequately  and  similarly  dealt  with  under  state  law. 


Public  Health  Services  165 


Bureau  of  Vital  Statistics 

SINCE  the  whole  structure,  plan,  program,  estimate  of  results  and  basis 
for  current  work,  as  well  as  the  science  of  municipal  demography  de- 
pend upon  the  system  and  organization  of  vital  statistics,  this  subject 
is  treated  in  a  special  manner  by  an  authority  in  this  field,  an  executive, 
an  author  and  a  student  of  social  problems. 

REPORT     AND     SUGGESTIONS     ON     CONDITION    OF    VITAL 

STATISTICS  IN  THE  DIVISION  OF  HEALTH,  CITY 

OF  CLEVELAND 

By  Louis  I.  Dublin,  Ph.  D. 

Vital  statistics,  that  is,  the  essential  facts,  the  rates  and  percentages 
dealing  with  population,  births,  deaths  and  the  incidence  of  disease,  by 
which  the  result  of  work  for  health  protection  is  measured,  upon  which 
plans  for  improvement  as  well  as  sanitary  and  administrative  policies  are 
based  or  determined,  are  to  all  intents  and  purposes  non-existent  in  the 
Division  of  Health  of  the  city  of  Cleveland. 

On  April  8,  1920,  there  was  not  yet  available- for  the  use  of  the  Health 
Commissioner  of  the  city  the  crude  or  general  death  rate  for  the  year  1919, 
nor  even  the  record  of  the  number  of  deaths  from  all  causes  which  occurred 
in  Cleveland  in  1919. 

The  birth  rate  for  1919  was  out  of  the  question;  for,  if  any  figure  was 
quoted,  it  would  obviously  be  unreliable,  since  non-reporting  of  births  is 
very  frequent  among  the  rank  and  file  of  physicians  and  midwives  in  Cleve- 
land. In  other  words,  the  health  authorities  of  this  city  have  not  at  hand 
the  most  vital  facts  as  to  their  community.  They  do  not  know  what  effect 
their  work  has  on  the  community;  in  what  respects  it  is  effective  and  in  what 
respects  it  is  not.  Except  through  conjecture,  they  cannot  know  the  dis- 
tricts and  sections  of  the  city  in  which  their  work  is  most  necessary  and 
those  in  which  it  is  not  quite  so  necessary.  Nor  can  they  estimate  the  per- 
sonnel required  to  do  a  specific  amount  of  work  nor  the  probable  cost  of  such 
work.  Cleveland  is  today  conducting  its  health  work  in  a  manner  typical 
of  American  cities  twenty  years  ago.  It  has  apparently  not  yet  learned  the 
very  obvious  lesson  that  both  economy  and  efficiency  require  a  system  of 
record  keeping  which  will  at  once  permit  the  development  of  a  scientific 
health  program  and  at  the  same  time  make  possible  such  supervision  and 
control  of  the  service  rendered  as  to  indicate  its  effect  and  its  value. 

Such,  then,  is  the  present  status  of  this  very  important  branch  of  the 
health  work  of  the  city  of  Cleveland.  The  picture  does  not  well  become  a 
city  of  close  to  eight  hundred  thousand  people,  ranking  fifth  among  the 
municipalities  of  America;  a  city  justly  priding  herself  on  her  vast  resources 
and  her  unquestioned  prosperity;  on  the  variety  and  extent  of  her  industries; 
on  her  favorable  and  healthy  location  and  on  the  right-mindedness  of  her 
officials  and  her  people.  Cleveland  is  rightfully  a  proud  and  progressive 
city.     In  few  cities  of  America  does  one  meet  more  forward-looking  citizens. 


166  Hospital  and  Health  Survey 

But,  these  citizens,  it  seems,  have  not  heard  of  the  necessity  of  applying 
arithmetic  to  the  problems  of  their  public  health,  or  to  those  other  aspects 
of  municipal  government  which  closely  affect  the  general  welfare.  It  is  at 
this  time  almost  impossible  to  present  a  demographic  picture  of  this  city. 

It  must  not  be  supposed  from  the  above  that  the  city  of  Cleveland  is 
niggardly  in  providing  the  means  for  work  so  essential  to  its  health  activities 
and  general  welfare.  About  $7,000  is  to  be  spent  in  1920  in  salaries  alone 
to  carry  on  the  vital  statistics  of  the  Division  of  Health.  In  addition, 
there  is  the  cost  of  the  equipment  of  tabulating  machinery,  of  records  and 
files,  of  furniture  and  office  space.  But  proper  and  necessary  results  are 
not  obtained  from  this  expenditure.  There  is  a  registrar  at  a  salary  of 
$1,750.  He  is  a  practising  physician  whose  duties  are,  as  far  as  could  be 
determined,  limited  to  countersigning  birth  and  death  certificates.  These 
duties  occupy  about  an  hour  a  day.  A  young  lady,  designated  statistician, 
at  a  salary  of  $1,520,  is  untrained,  but  is  interested  and  conscientious.  She  does 
what  she  can  undirected.  She  runs  the  little  division  that  exists  in  the  depart- 
ment, tabulates  the  records  and  has  general  supervision.  But  she  is  com- 
pletely out  of  touch  with  her  superiors  and  has  no  experience  of  her  own  to 
fall  back  on.  Several  other  clerks,  varying  in  number  from  four  to  eight, 
prepare  transcripts  of  birth  and  death  certificates,  file  these  and  carry  out 
the  simple  routine  required  by  the  law. 

Under  such  direction  it  is  obvious  that  the  $7,000  provided  for  the  vital 
statistics  work  is  almost  completely  wasted.  Yet,  it  is  important  to  recog- 
nize what  is  being  done.  Certificates  of  birth  and  death  are  received.  These 
are  copied  for  the  local  files  and  the  originals  sent  to  the  State  Department 
of  Health.  The  copies  that  are  kept  locally  are  bound  into  permanent 
volumes.  An  alphabetical  index  is  also  made  to  facilitate  finding  certificates 
which  are  arranged  numerically.  Gross  carelessness  in  the  acceptance  of 
illegal  and  incomplete  birth  and  death  certificates,  and  errors  in  names, 
addresses  and  dates  of  copies  left  in  Cleveland  files  f6r  reference  are  of  fre- 
quent occurrence.  Occasionally,  as  implied  above,  an  attempt  is  made  to 
count  certificates  and  to  report  to  the  Health  Officer  the  total  number  of 
births  and  deaths  for  certain  periods;  but  such  effort  is  always  belated. 
At  no  point  is  there  any  evidence  that  those  who  work  at  this  material  have 
the  training  necessary  to  do  so.  The  important  item  of  cause  of  death  is, 
for  example,  assigned  by  a  clerk  whose  decisions  with  reference  to  joint 
causes  or  otherwise  complicated  statements  have  no  value  as  to  their  authen- 
ticity or  agreement  with  the  rules  of  practice  of  the  Census  Bureau. 
No  effort  is  made  to  check  the  most  important  fact,  the  completeness  of 
registration.  No  list  of  physicians  and  midwives  is  used  in  this  department, 
although  one  is  available  in  the  office  of  the  Health  Commissioner.  No 
tabulations  are  made  of  the  numbers  of  reports  received  from  each  physician 
and  midwife.  No  correspondence  is  had  with  any  one  of  these  when  no  certifi- 
cates are  received  for  long  periods  of  time.  No  check  of  any  kind  is  carried 
on  to  determine  whether  birth  or  death  certification  is  complete.  Checks 
that  have  been  made  by  other  agencies  (voluntary  and  official)  indicate  that 
the  birth  registration  may  be  from  60  to  80  per  cent  complete,  the  figures 
varying  during  recent  years. 


Public  Health  Services  167 

The  following  check  made  by  the  Survey  will  serve  to  gauge  to  some  de- 
gree the  extent  of  incompleteness: 

The  records  of  614  children  under  two  years  of  age  who  were  bornlin 
Cleveland  were  obtained  through  the  Division  of  Health  nurses,  and  the 
Visiting  Nurse  Association.  These  records  were  checked  at  the  Bureau  f of 
Vital  Statistics  and  only  383  or  62%  were  found  registered  under  the  same 
date,  spelling  of  name,  etc.  These  same  cases  and  55  others,  a  total  of 
669,  were  re-checked  and  a  search  made  under  every  probable  spelling  and 
under  the  records  for  several  months,  and  522  or  78%  were  found  registered. 

No  monthly  records  of  births,  deaths,  or  of  cases  of  reportable  disease 
are  made  available  to  the  citizens  of  Cleveland.  No  bulletins  are  issued  by 
the  Division  of  Health  and,  as  far  as  could  be  ascertained,  no  printed  annual 
statement  has  been  prepared  for  several  years.  The  city  of  Cleveland 
presents  a  rare  opportunity  among  the  larger  cities  of  the  country  to  begin 
de  novo  in  fashioning  a  system  for  its  record  keeping. 

A  system  of  vital  statistics  can  readily  be  instituted  which  shall  reflect 
the  tone  of  the  reorganized  health  service.  It  must  be  part  and  parcel  of  such 
a  health  service;  an  integral  part  of  a  comprehensive  effort  to  conserve  the 
vital  resources  of  the  city  to  the  utmost. 

Such  a  service  will  be  embraced  under  three  heads: 

1.  Registration  of  births,  deaths  and  cases  of  sickness. 

2.  Tabulations  and  reports. 

3.  Investigation,  research  and  health  information. 

1.  The  first  subdivision  is  basic  to  all  the  rest,  for  without  the  primary 
registered  facts,  tabulations,  reports  or  investigations  cannot  be  made.  The 
state  law  requires  that  every  birth  and  death  in  the  city  shall  be  reported 
within  ten  days.  It  is  the  duty  of  the  Registrar  to  see  that  this  requirement 
of  the  law  is  enforced.  The  first  step  in  such  enforcement  is  to  have  a  complete 
list  of  physicians  and  midwives  available.  At  regular  intervals  reports  of 
births  should  be  credited  to  the  certifying  physicians  and  midwives.  Those 
from  whom  there  are  no  reports  or  only  a  very  small  number  should  be 
questioned  to  determine  whether  they  are  negligent  in  reporting.  Reports 
of  births  should  also  be  checked  against  lists  of  baptisms,  newspaper  notices 
and  similar  sources  of  information.  Records  of  deaths  of  infants  under  one 
year  of  age  should,  as  a  matter  of  routine,  go  through  the  Registry  Room 
to  determine  whether  they  had  been  previously  registered  as  births.  Records 
of  stillbirths  should  figure  equally  among  births  and  deaths.  The  names  of 
those  physicians  and  midwives  who  are  particularly  negligent  in  their  duties 
of  registration  would  soon  be  available.  An  effort  could  then  be  concentrated 
on  them  to  mend  their  ways.  It  will  be  necessary  in  some  cases  to  prosecute 
physicians  and  midwives  according  to  law  as  a  lesson  to  others  that  the 
authorities  are  determined  to  make  birth  registration  complete.  It  will  be 
necessary  in  this  connection  to  obtain  the  cooperation  of  the  State  Registrar 
and  of  the  State  local  prosecuting  authorities  who  share  in  the  responsibility 
for  enforcing  the  vital  statistics  law. 


168  Hospital  and  Health  Survey 

Death  registration  in  Cleveland  is  probably  in  a  satisfactory  condition, 
although  no  effort  has  as  yet  been  made  to  determine  the  comoleteness  of 
registration.  Physicians  uniformly  take  more  seriously  the  requirements  of 
death  registration.  It  would,  nevertheless,  be  useful  at  certain  intervals  if 
an  effort  "were  made  to  check  the  list  in  the  registry  office  with  lists  of  deaths 
obtained  from  independent  sources,  such  as  hospitals  and  institutions  for 
the  aged  and  dependent,  newspaper  lists  of  decedents,  etc.  It  is  conceiv- 
able that  through  these  means  physicians  who  neglect  occasionally  to  report 
a  death  or  who  unduly  delay  their  reports  will  be  discovered. 

Once  received,  the  certificates  of  births  and  deaths  must  be  transcribed, 
the  originals  sent  to  the  State  Registrar,  and  the  certified  copies  bound  and 
made  available  for  easy  access  and  future  reference.  This  necessitates  the 
preparation  of  additional  index  volumes  or  card  records  of  births  and  deaths, 
arranged  alphabetically  by  name  with  a  corresponding  registry  number  of 
the  original  certificates.  It  goes  without  saying  that  such  indices  and  the 
transcripts  themselves  should  be  legibly  written  and  checked  as  to  accuracy. 
The  transcripts  must  be  bound  at  regular  intervals  in  consecutive  order  of 
the  file  number  and  placed  where  they  can  be  easily  accessible  and  safe  from 
mishandling  or  destruction  by  fire.  At  the  present  time  the  file  room  of  the 
Division  of  Health  is  in  bad  condition.  It  is  a  general  storeroom  as  well  as  file 
room  and  it  is  altogether  too  small  and  too  dark  to  permit  good  work  to 
be  done.  Batches  of  birth  and  death  certificates  are  in  constant  danger  of 
being  misplaced  under  present  conditions. 

In  addition  to  the  registration  of  births  and  deaths,  the  Bureau  of  Vital 
Statistics  should  serve  the  Bureau  of  Communicable  Diseases  of  the  Division 
as  the  repository  of  the  records  of  cases  of  communicable  disease  reported  as 
required  by  law.  While  these  records  are  primarily  intended  for  the  guidance 
of  the  Bureau  of  Communicable  Diseases  for  administrative  health  work,  it 
would  be  economical  if  the  cases  were  communicated  to  the  Registrar  for 
tabulation  to  show  from  week  to  week,  and  at  other  longer  intervals,  the 
condition  of  the  city  with  reference  to  infectious  and  other  reportable  diseases. 

It  is  also  recommended  that  this  division  cooperate  with  the  Cleveland 
Hospital  Council  with  a  view  to  recording  the  number  and  character  of 
patients  receiving  care,  together  with  a  statement  of  the  diagnosis,  and  the 
other  basic  facts  for  the  sick  in  each  of  the  several  wards  or  preferably  in  the 
sanitary  areas  of  the  city.  This  phase  of  hospital  statistics  will  be  treated 
in  another  section  of  this  report  and  will  not,  therefore,  require  further  dis- 
cussion at  this  point. 

The  present  clerical  force  is  quite  adequate  to  insure  the  performance  of 
the  registration  work  of  the  Vital  Statistics  Bureau.  All  that  is  needed  is  intelli- 
gent supervision  and  leadership.  If  the  registration  of  communicable  disease 
and  hospital  cases  is  desired  as  an  added  activity  of  the  division,  an  addi- 
tion of  one  or,  at  most,  two  clerks  will  be  necessary. 

2.  Once  the  certificates  of  birth  and  death  are  received  and  the  number  certi- 
fied as  correct,  it  is  the  function  of  the  Registrar  to  tabulate  the  result  at  re- 
gular interval.s  A  weekly  report  of  the  number  of  births  and  deaths  registered 
should  be  available.     The  health  officer  should  receive  on  Monday  of  each 


Public  Health  Services  169 

week  a  statement  from  the  Registrar  covering  the  number  of  births  and 
deaths  reported  during  the  preceding  week.  Both  births  and  deaths  should 
be  tabulated  by  sanitary  areas  and  by  Health  Districts  and  the  numbers 
compared  with  those  for  the  corresponding  week  of  the  previous  year.  Deaths 
should  be  further  subdivided  as  to  broad  age  periods  and  by  the  principal 
causes  to  show  the  current  mortality  among  infants,  and,  especially  from 
the  infectious  diseases.  At  the  close  of  each  month  a  more  detailed  monthly 
statement  should  be  prepared  and,  at  the  close  of  the  year,  a  full  annual 
report  should  be  prepared.  A  series  of  tables  are  given  in  the  appendix 
which  are  designed  to  show  the  facts  required  for  each  year  for  a  city  of  the 
size  and  importance  of  Cleveland. 

The  Registrar  should  also  tabulate  and  report  on  the  cases  of  sickness  in 
the  community  so  far  as  records  for  such  cases  are  available.  Under  this 
head  two  important  activities  may  be  distinguished: 

(a)  The  Statistics  of  Infectious  and  Notifiable  Diseases. 

Under  the  first  head  the  Registrar  will  cooperate  with  the  Director  of 
the  Bureau  of  Communicable  Diseases.  It  should  be  the  duty  of  the  Regis- 
trar to  make  pin  maps  for  the  cases  indicating  the  incidence  of  disease  by 
sanitary  areas  or  by  Health  Districts  of  the  city.  He  should  weekly,  monthly, 
quarterly  and  annually  compile  the  figures  showing  the  prevalence  of  the 
several  diseases  for  the  sanitary  areas.  He  should  make  comparisons  with 
the  incidence  of  such  diseases  in  previous  years  and  keep  the  Health  Com- 
missioner and  the  others  of  the  Administrative  Staff  informed  of  impending 
epidemics  and  of  the  distribution  of  cases  in  the  several  areas  of  the  city. 
Such  work,  it  is  true,  is  rarely  done  by  registrars  in  American  cities.  It  is 
carried  on  usually,  when  at  all,  by  the  Director  of  the  Bureau  of  Communi- 
cable Diseases;  but  the  work  is  essentially  statistical  and  could  be  more 
economically  performed  by  the  Statistical  Bureau.  There  is  no  statistical 
work  that  will  produce  greater  dividends  than  the  careful  compilation  of 
records  of  disease,  intelligently  interpreted  with  reference  to  distribution  by 
health  districts,  sanitary  areas  or  by  wards,  and  by  age,  color  and  nativity 
of  the  population.  When  properly  correlated  with  the  registration  of  deaths 
from  these  same  diseases,  it  should  be  possible  to  prepare  tables  showing,  in 
addition  to  the  attack  or  morbidity  rate,  the  lethal  or  ease-fatality  rate,  which 
would  indicate  the  severity  of  the  epidemic  at  any  particular  time. 

(b)  Hospital  Statistics. 

Cleveland  finds  itself  exactly  in  the  same  position  as  do  all  cities  in  the 
United  States  with  reference  to  a  knowledge  of  the  work  of  its  hospitals. 
In  no  American  city  of  any  size  is  it  possible  to  give  the  total  number  of  cases 
admitted  to  hospitals,  both  public  and  private,  the  diseases  for  which  entrance 
was  sought,  the  age  and  sex  distribution  of  the  patients,  the  duration  of 
treatment  and  the  result  of  the  treatment.  It  is  a  blemish  on  the  excellent 
work  done  by  hospitals  that  this  phase  of  their  activities  has  been  left  un- 
developed almost  without  exception  in  the  United  States.  For  Cleveland 
this  represents  an  opportunity.  For,  should  this  city  organize  an  effective 
bureau  in  its  health  division  under  the  direction  of  a  competent  vital  statis- 


170  Hospital  and  Health  Survey 

tician,  it  would  be  a  relatively  simple  matter  to  put  into  operation  a  plan 
which  will  result  in  the  compilation  of  just  such  data  with  reference  to  hos- 
pitalization in  this  city.  The  necessity  of  such  records  of  hospital  care  is 
never  questioned;  but  nowhere  have  the  necessary  steps  been  taken  to 
assure  the  receipt  of  the  facts.  In  the  matter  of  organization,  it  would  be 
necessary  only  to  establish  a  central  office,  preferably  in  the  Bureau  of  Vital 
Statistics  of  the  city,  where  uniform  reports  would  be  received  from  each  of 
the  hospitals  of  the  city  for  each  case  on  its  discharge.  Such  a  standard  form 
would  include  such  basic  items  as  age  of  the  patient,  sex,  color,  nativity,  occu- 
pation, duration  of  residence  in  Cleveland,  address,  diagnosis  on  admission 
and  at  discharge,  a  brief  summary  of  the  treatment,  duration  of  the  treat- 
ment, the  date  of  discharge  and  condition  on  discharge;  a  statement  of  the 
social  service  work  done  or  contemplated  would  make  a  valuable  addition. 
It  would  be  necessary  only  for  the  hospitals  of  the  city  to  agree  upon  a  simple 
blank  including  such  items  as  these,  and  to  send  them  as  completed  to  the 
central  record  office  immediately  upon  the  discharge  of  the  patient.  A  nomen- 
clature and  classification  of  diseases  and  of  conditions  or  states  of  the  patients 
on  discharge  should  also  be  agreed  upon. 

In  the  central  office  these  records  would  be  edited  and  otherwise  prepared 
for  transfer  to  perforated  cards  which  would  then  be  sorted  and  tabulated  by 
mechanical  devices.  At  comparatively  low  cost,  it  should  be  possible  at 
the  end  of  each  quarter  and  at  the  end  of  the  year  to  have  available  a  series  of 
tables  showing  for  each  hospital  and  for  all  hospitals  combined,  the  essential 
facts  for  the  cases  discharged  during  the  period. 

From  the  point  of  view  of  the  city  such  information  would  be  of  the 
greatest  value  in  indicating  the  adequacy  of  hospital  care  then  available 
and  the  need  for  additional  hospitals  and  their  location.  It  is  conceivable 
that  hospitals  are  now  improperly  placed  with  reference  to  the  outlying  sec- 
tions of  the  city.  A  study  of  the  wards  in  which  patients  are  located  as 
compared  with  the  location  of  the  hospitals  in  which  they  have  been  cared 
for,  would  indicate  opportunities  for  greater  service  through  more  effective 
location  of  hospital  structures.  Causes  for  undue  competition  between  hos- 
pitals could  be  removed  through  this  means.  But,  more  important,  will  be 
the  effect  upon  the  management  of  hospitals  in  the  city  in  standardizing 
record  keeping,  in  bringing  them  together  for  mutual  conference  to  learn 
why  certain  types  of  cases  are  better  cared  for  in  one  hospital  than  in  another, 
why,  at  any  rate,  one  hospital  has  a  lower  lethality  rate  for  certain  diseases 
or  surgical  conditions  than  another.  Comparisons  could  also  be  made  be- 
tween the  duration  of  stay  in  certain  hospitals  in  treating  like  cases.  The 
opportunity  for  constructive  criticism  is  unlimited.  Such  a  plan  as  this 
could  be  operated  tactfully  with  the  cooperation  of  the  hospital  authorities. 
The  cost  for  such  an  activity  should  very  properly  be  met  by  the  Hospital 
Council,  but  the  maximum  will  not  be  more  than  a  small  item  for  each  of 
the  hospitals.  The  Division  of  Health  would  supply  only  the  use  of  its 
machinery  and  the  directing  care  of  its  statistician.  For  the  city,  however, 
and  for  the  Health  Division  especially,  this  will  mean  that,  for  the  first 
time,  it  will  have  a  knowledge  of  morbidity  in  the  population  which  is  cared 
for  through  the  agencies  of  the  hospitals.  This  is  certainly  an  important 
phase  of  the  health  problem  of  the  city.     The  patients  cared  for  by  the 


Public  Health  Services  171 


Visiting  Nurse  Association  should  on  discharge  be  reported  in  a  similar  man- 
ner to  the  Bureau  of  Vital  Statistics  through  the  central  office  of  the  Asso- 
ciation.    The  nursing  service  is  practically  a  great  extra-mural  hospital. 

3.  The  above  outline  of  the  work  of  the  Bureau  of  Vital  Statistics  is  a  con- 
servative statement  of  what  such  work  may  profitably  include.  It  will  prob- 
ably be  all  that  an  efficient  registrar  or  statistician  with  a  limited  staff  will 
be  able  to  undertake  during  the  first  few  years  of  his  incumbency.  It  is 
conceivable,  however,  that  if  the  Registrar  is  carefully  chosen  and  is  sup- 
ported by  the  Health  Commissioner  and  by  the  private  and  other  official 
agencies,  his  department  will  gradually  absorb  other  work  along  the  lines 
of  investigation  and  research  which  it  can  efficiently  perform.  Such  work 
should  lie  directly  in  the  field  of  public  health  and  social  welfare.  It  should 
be  the  duty  of  the  Registrar  to  conduct  statistical  investigations  into  the 
effectiveness  of  the  various  experiments  undertaken  by  the  Division  of  Health, 
be  it  in  organizing  the  health  service  along  district  rather  than  central  lines,  or 
in  determining  the  efficiency  of  generalized  as  against  specialized  visiting 
nursing  of  the  sick,  or  the  best  method  of  caring  for  certain  diseases,  such  as 
pneumonia  and  the  communicable  diseases  of  children  whether  in  hospitals 
or  at  home  under  proper  medical  and  nursing  care. 

The  Registrar  may  also  well  undertake  to  prepare,  in  cooperation  with 
other  official  and  semi-private  agencies,  annually  or  biennially,  a  Year-Book 
for  the  City  of  Cleveland  in  which  the  chief  facts  of  the  population  should  form 
the  central  items.  This  report  would  include  data  covering  the  city  and  its 
resources.  The  Registrar  would,  in  this  sense,  be  a  compiler  and  editor  of 
materials  received  from  the  several  heads  of  divisions  of  the  city  administra- 
tion. From  the  Commissioner  of  Streets  he  will  receive  annually  a  statement 
covering  miles  of  streets  now  paved  and  cleaned  and  otherwise;  from  the 
Commissioner  of  Engineering  and  Construction  and  from  the  Commissioner 
of  Water,  the  essential  facts  concerning  those  departments;  from 
the  judges  and  District  Attorney  facts  concerning  crime;  from  the  school 
commissioners,  facts  for  the  educational  system;  from  the  Commissioner  of 
Internal  Revenue,  located  in  Cleveland,  items  related  to  incomes  and  the 
value  of  manufacturing  products.  The  result  would  be  a  Year  Book  which 
would  reflect  the  greatest  credit  upon  the  city  because  it  would  show  in 
narrow  compass  the  true  greatness  of  the  community.  It  would  present 
briefly  a  summary  of  the  major  activities  of  the  population,  its  resources  in 
men,  the  value  of  its  products,  the  source  of  its  revenue.  It  should  be  a 
most  valuable  reference  guide  for  the  administration  of  the  city  toward  new 
projects  and  an  expression  of  the  progressive  spirit  of  its  citizens. 

Such  a  plan  as  this  looks  into  the  future,  but  it  is  not  at  all  chimerical. 
\11  of  it  can  be  accomplished  if  only  the  first  step  be  taken;  namely,  to  obtain 
or  the  Division  of  Health  a  man  properly  qualified  to  do  the  immediate 
statistical  work  of  that  department  but  with  sufficient  wisdom  and  capacity 
:o  assure  his  assumption  of  larger  responsibilities  in  the  future.  Everything 
ncluded  above  will  ultimately  reflect  favorably  upon  the  health  of  the  people 
md  justifies  the  inclusion  of  this  scheme  under  the  activities  of  the  Division 
>f  Health. 


172  Hospital  and  Health  Survey 


Introduction  to  Cleveland  Tables 

Tables  X. -XXXVIII.  (Appendix)  present  an  outline  of  a  complete  system 
of  vital  statistics  for  the  health  department  of  a  city  of  the  size  of  Cleve- 
land. It  will  not  be  necessary  to  prepare  all  these  tables  each  year. 
The  first  seven  will  be  valuable,  primarily,  for  census  years  when  detailed 
and  accurate  data  for  the  population  are  available.  Other  tables  have 
special  bearing  on  certain  diseases  and  conditions  and  need  appear  only 
occasionally  as  it  is  desired  to  arouse  interest  in  them.  Much  will  depend  on 
the  facilities,  both  in  funds  and  personnel,  available  to  the  registrar.  With  gen- 
erous support  he  may  give  a  fairly  complete  presentation  of  the  vital  resources 
and  activities  of  the  population  from  year  to  year.  But  with  limited  support 
it  will  be  necessary  for  him  to  use  only  those  tables  which  give  the  more 
essential  facts. 

RECOMMENDA  TIONS 

It  is  recommended  that: 

1.  A  competent  statistician  be  put  in  charge  of  the  Bureau  of  Vital  Statistics  with  sufficient 
support  to  carry  through  a  comprehensive  program  of  record  keeping  for  the  Division 
of  Health. 

2.  Birth  registration,  which  is  now  very  defective,  be  made  complete.  This  may  be  accom- 
plished through  the  following  steps: 

(a)  A  complete  list  of  physicians  and  midwives. 

(b)  A  check-back  at  regular  intervals  of  all  births  reported  to  th^  physicians 
and  midwives  reporting  them. 

(c)  A  follow-up  of  those  physicians  doing  obstetrical  work  and  of  all  mid- 
wives  who  do  not  make  any  or  a  small  number  of  reports. 

(d)  A  check-back  of  all  infant  deaths  to  the  birth  registration  list,  and  if  no 
record  of  birth,  the  case  to  be  followed  up  to  determine  the  negligent 
physician  or  midwife. 

(e)  The  prosecution  of  persons  persistently  violating  the  law. 

3.  The  cooperation  of  the  local  and  State  Medical  Society  be  obtained  as  a  preliminary 
to  subsequent  enforcement  of  the  law. 

4.  Provision  be  made  for  the  editing,  tabulating  and  analyzing  of  certificates  of  death. 

5.  More  care  be  taken  to  file  birth  and  death  certificates  to' provide  against  their  loss  or 
misplacement. 

6.  The  Division  of  Health  consider  the  problem  of  morbidity  statistics  and  make  pro- 
vision for  the  study  of  records  of  communicable  disease,  and  of  hospital  and  Visiting 
Nurse  Association  dis<*harge  certificates. 

7.  Provision  be  made  for  such  investigation  and  research  work  in  the  Division  of  Health 
as  will  keep  the  Commissioner  informed  as  to  the  effectiveness  of  the  various  activities 
of  the  department  and  of  such  experimental  work  as  is  undertaken. 

8.  The  Registrar  compile  a  year-book  covering  the  health  as  well  as  the  social  and  economic 
data  of  the  city.  ' 


Public  Health  Services  173 


New  Activities  Proposed  for  the  Division  of  Health 

EACH  of  the  existing  bureaus  of  the  Division  of  Health  is  called  upon 
by  public  demand,  by  appeal  or  pressure  of  private  agencies  or  by  the 
initiative  of  its  own  officers  and  the  Commissioner  of  Health  to  add 
here  and  there  a  temporary  or  permanent  function  or  service.  This  will  go 
on  and  should  go  on  to  the  end  of  time.  At  the  moment  there  are  a  few 
functions  which  our  study  and  the  force  of  circumstances  seem  to  impose 
upon  the  Division  of  Health.     We  refer  to: 

1.  Inspection  and  supervision  of  sanitation  and  medical  services  in 
institutions  where  public  and  private  charges  are  harbored  temporarily  or 
for  life. 

2.  Inspection,  technical  advice  and  protection,  for  the  industries  and 
commercial  establishments  of  the  city,  to  diminish  the  hazards  to  health, 
in  occupations. 

3.  Medical  examination  service  for  the  city  employes. 

4.  Public  health  education. 

5.  Supervision  of  and  provision  for  the  victims  of  habit-forming  drugs 
and  protection  of  the  public  against  the  illicit  introduction  of  these  drugs 
in  trade. 

A  brief  statement  on  each  of  these  needs  follows: 

INSTITUTIONAL  INSPECTION 

The  Griswold  Act  of  the  last  legislature  recognizes  the  need  for  institu- 
tional inspection  as  a  public  health  measure,  and  in  Section  1261-31  author- 
izes frequent  inspection  of  infirmaries,  children's  homes,  workhouses,  jails, 
or  other  charitable,  benevolent  or  penal  institutions,  including  physical  ex- 
amination of  the  inmates  whenever  necessary  by  representatives  of  health 
departments.  As  a  safeguard  against  communicable  disease  alone,  such  an 
activity  is  justified  and  sooner  or  later  the  Division  of  Health  must  deal  with 
this  important  subject  in  an  organized  way.  Owing  to  the  nature  of  the 
problem  most  of  this  work  must  be  done  by  physicians.  By  adding  to  the 
present  number  of  district  physicians  a  partial  inspection  of  institutions  can 
be  begun  in  much  the  same  way  that  the  division  has  begun  school  inspec- 
tion in  parochial  schools,  through  the  public  health  nurse. 

Since  no  information  was  available  as  to  the  sanitary  conditions  which 
prevail  in  institutions  or  as  to  medical  service,  a  special  study  was  made  of 
these  aspects  of  the  institutional  life  of  children,  in  cooperation  with  the 
investigator  of  the  Welfare  Federation  who  studied  the  social,  economic, 
educational,  recreational  and  spiritual  environment  of  the  institutional  chil- 
dren. The  results  of  the  combined  study  have  been  presented  to  the  superin- 
tendents and  boards  of  managers  of  the  various  institutions  studied,  in  much 
:he  same  way  in  which  the  reports  of  the  Survey  on  hospitals  were  made 
available  directly  to  hospital  trustees  and  administrators. 


174  Hospital  and  Health  Survey 

The  study  of  the  institutions  fell  under  three  headings:  Child  Caring 
Institutions  proper,  Boarding  Homes  for  Children,  Day  Nurseries.  Dr. 
Henry  G.  McAdam,  the  chief  of  the  division  of  institutional  inspection  of 
the  New  York  City  Department  of  Health  aided  by  inspectors  of  the  Board 
of  State  Charities  and  physicians  of  Cleveland  engaged  to  make  medical 
examinations  of  children,  did  the  field  work.  The  following  reports  were 
prepared  by  Dr.  McAdam. 

Report  ox  Child  Caring  Institutions  in  Cleveland 

Objects 

1 .  A  complete  physical  examination  of  at  least  1 5  %  of  the  inmates  of 
Child  Caring  Institutions. 

2.  A  Sanitary  Survey  of  the  building  or  buildings  housing  these  inmates. 

So  far  as  was  possible  the  children  examined  were  actually  divided  among 
those  who  had  been  in  the  institution  only  a  short  time,  and  those  who  had 
been  resident  for  from  six  months  to  a  number  of  years.  The  analysis  of 
these  findings  is  divided  according  to  whether  the  child's  length  of  stay  in 
the  institution  was  under  or  over  six  months. 

The  children  were  examined  for  defects  under  eleven  headings,  viz.: 
(1)  Vision,  (2)  Hearing,  (3)  Defective  Teeth,  (4)  Defective  Nasal  Breathing, 
(5)  Hypertrophied  Tonsils,  (6)  Defective  Nutrition,  (7)  Cardiac  Disease, 
(8)  Pulmonary  Disease,  (9)  Orthopedic  Defects,  (10)  Nervous  Disease,  (11) 
Miscellaneous. 

Under  the  heading,  Miscellaneous,  the  following  diseases,  defects  and 
conditions  found  during  the  examinations  were  noted: 

Enlarged  cervical  glands  Enlarged  Thyroid  glands 

Enlarged  axillary  glands  Adenoid  facies 

Conjunctivitis  Protruding  abdomen 

Redundant  foreskin  Acne 

High  arch  palate  Impetigo 

Enuresis  Furunculosis 

No  Uvula  Scabies 

Ringworm  Infection  of  legs 


Infection  of  back  Infection  of  right  heel 

Infection  of  buttocks  General  pallor 

Infection  behind  ear  Pasty  complexion 

Puffmess  under  eyes  Chronic  Otitis 


Representatives  of  the  Board  of  State  Charities,  under  direction,  use 
the  outline  that  is  used  in  inspection  of  similar  institutions  in  the  City  of 
New  York,  on  which  to  base  their  reports. 


. 


Public  Health  Services  175 

We  were  impressed  by  the  number  of  Homes  for  Children  that  had  in 
contemplation  new  buildings  or  new  locations,  or  both.  Among  those  where 
definite  plans  have  been  perfected,  are  the  following: 

1.  Cleveland  Protestant  Orphan  Asylum — Land  has  been  pur- 
chased and  plans  are  ready  for  a  new  structure. 

2.  Cleveland  Christian  Orphanage — It  is  almost  certain  that  this 
institution  will  be  in  a  new  building  within  a  year. 

3.  Jewish  Infant  Orphan  Asylum — Property  has  been  purchased 
and  plans  completed  for  removing  from  the  present  location  to  the  new 
quarters  within  a  year. 

4.  St.  Vincent's  Orphan  Asylum — Plans  have  been  perfected  and 
this  institution  will  move  into  new  buildings  inside  of  a  year. 

5.  Jewish  Orphan  Asylum — Plans  have  been  perfected  for  the  new 
buildings,  but  it  will  probably  be  three  years  before  a  change  is  made.  $25,000 
have  been  expended  in  necessary  alterations  of  the  present  place,  and  con- 
tracts for  $25,000  additional  expenditures  have  been  passed  by  the  com- 
mittee in  charge  of  the  budget. 

The  admission  procedures  followed  and  the  physical  condition  of  the  in- 
mates and  buildings,  varied  within  very  wide  limits,  and  individual  reports 
in  detail  have  been  prepared  for  each  institution. 

Summaries  of  the  examinations  of  the  inmates,  of  medical  service  pro- 
vided for  them,  and  of  the  results  of  the  sanitary  inspections  of  the  nineteen 
institutions  studied,  are  to  be  found  in  Tables  XXXIX. -XLI.  in  the  Ap- 
pendix. 

Summary  of  Medical  Service 

1.  Only  three  child-caring  institutions  out  of  the  total  of  19  investi- 
gated, provide  an  entrance  physical  examination. 

2.  Only  three  institutions  out  of  the  total  of  19  have  an  admission 
quarantine  to  prevent  new  inmates  from  bringing  contagion  into  the  institu- 
tion. 

3.  Eleven  institutions  have  ample  isolation  facilities,  and  eight  do  not. 

4.  Thirteen  institutions  have  adequate  hospital  facilities,  while  six 
have  none,  or  inadequate  facilities. 

5.  Not  a  single  institution  of  the  19  investigated  conducts  periodic 
physical  re-examinations  of  the  inmates. 

6.  Thirteen  of  the  Homes  investigated  have  Hospital  and  Dispensary 
affiliations,  while  six  maintain  no  relationship  of  this  nature. 

7.  Children  are  allowed  as  visitors  in  17  of  the  institutions  investigated. 
In  only  two  is  this  prohibited. 


176  Hospital  and  Health  Survey 

There  was  no  way  to  determine  what  percentage  of  the  children  examined 
had  had  corrective  work  done  during  their  stay  in  the  institution,  in  as  much 
as  none  of  the  institutions  conduct  re-examinations  of  the  children. 

Without  records,  the  value  of  the  work  cannot  be  determined.  In  some 
of  the  institutions  visited,  information  on  loose  pieces  of  scrap  paper  were 
the  only  records  kept. 

Only  three  Child  Caring  Institutions  give  a  complete  physical  examination 
on  admission  and  keep  records  of  the  findings.  In  one  of  these  (The  Deten- 
tion Home)  a  trained  nurse  conducts  the  examinations.  The  other  two  are 
the  Cleveland  Christian  Orphanage  and  the  Cleveland  Protestant  Orphan 
Asylum. 

Adequate  admission  quarantine  is  of  great  importance  as  an  administra- 
tive feature  in  Child  Caring  Institutions.  If  every  child  on  admission  to 
an  institution  is  placed  in  quarantine  for  the  incubation  periods  of  contagious 
diseases,  before  being  allowed  to  mingle  with  the  other  children  he  or  she 
cannot  spread  communicable  diseases  in  that  institution  and  the  only  source 
of  contagion  must  be  from  the  outside.  Furthermore,  if  children  (who  are 
more  prone  to  contract  the  ordinary  contagious  diseases  than  adults)  are 
excluded  as  visitors  to  institutions,  contagion  will  be  reduced  to  a  minimum. 

During  our  investigation  no  special  effort  was  devoted  to  the  subject  of 
venereal  diseases.  We  found,  however,  with  reference  to  penal  institutions 
particularly,  that  this  subject  received  the  attention  it  deserved.  Theo- 
retically, Wassermann  tests  should  be  made  on  all  new  admission  sand 
vaginal  smears  made  of  all  females.  For  practical  purposes  it  would  prob- 
ably be  sufficient  to  perform  Wassermann  tests  where  indicated  by  clinica 
signs  or  symptoms,  and  to  make  vaginal  smears  in  the  presence  of  vaginal 
discharges. 

RECOMMEND  A  TIONS 

1.  No  child-caring  institution  should  be  allowed  to  operate  without  a  permit. 

2.  Prior  to  the  issuance  of  a  permit  the  applicant  should  show: 

(a)  The  necessity  for  the  institution. 

(b)  That  there  is  a  proper  plant  in  which  to  conduct  the  proposed 
institution. 

(c)  The  financial  ability  to  maintain  the  institution  for  which  the  per- 
mit is  asked  properly  in  all  respects. 

(d)  Capability  for  efficient  management. 

3.  Permits  should  be  issued  only  after  compliance  with  certain  equipment  and  serv- 
ice standards  which  should  include  the  following: 

(a)  Protection  against  fire  hazards. 

(b)  Protection  against  accidents  due  to  unguarded  machinery. 

(c)  Type  of  building  should  be  fire-proof  if  in  excess  of  20  feet  in  height. 

(d)  No  over-crowding.  A  minimum  of  600  cubic  feet  of  air  space 
should  be  allowed  to  each  child,  except  when  very  young  infants  only  are 
housed,  when  300  cubic  feet  should  be  allowed  for  each  child. 


Public  Health  Services  177 

(e)  Proper  heat,  light,  ventilation,  refrigeration  and  screening  of  building. 

(f)  Adequate  toilet  and  bathing  facilities. 

(g)  Adequate  laundry  facilities. 

(h)  Adequate  isolation  and  quarantine  facilities. 

(i)    Provision   for   regular   physical   examinations   and   re-examinations 
of  the  children,  either  by: 

1.  The  attending  physician  of  the  institution,  or 

2.  The  clinics  of  the  Division  of  Health,  or 

3.  A  special  corps  of, physicians  employed  by  the  city. 

4.     Regular  and  adequate  inspection  and  supervision  by  the  municipal  government. 

Boarding  Homes  for  Children 

No  sanitary  survey  was  made  of  the  boarding  homes  for  children  under 
the  care  of  the  Humane  Society,  but  57  "boarded  out"  children  received 
physical  examinations.  The  results  are  given  in  the  Appendix,  Table  XLII. 
A  description  of  the  present  procedures  for  the  medical  supervision  of  these 
children  follows:* 

"The  medical  care  of  children  in  boarding  homes  in  general  is  provided  by  the  Division 
of  Health  and  the  Babies'  Dispensary  as  follows:  Children  under  three  years  of  age, 
when  received  by  the  Humane  Society  are  examined  at  the  Babies'  Dispensary  and  are 
tested  for  venereal  disease  and  tuberculosis;  the  children  are  brought  back  for  reading  of 
tests  and  re-examination  at  the  time  that  the  dispensary  specifies.  Medical  care  for  the 
children  is  provided  at  the  dispensary  as  long  as  the  doctors  advise.  The  diet  for  the 
children  is  prescribed  at  this  dispensary  as  long  as  the  children  are  brought  there.  Milk 
for  babies  under  fifteen  months  of  age  is  ordered  and  provided  by  the  dispensary  and  is 
free  for  children  whose  parents  are  unable  to  pay. 

"After  the  children  are  discharged  from  the  Babies'  Dispensary  they  are  taken  by  the 
boarding  mother  to  the  prophylactic  dispensaries  of  the  Division  of  Health  in  the  district 
in  which  the  boarding  home  is  located.  They  are  taken  to  these  dispensaries  once  in  two 
weeks  and  are  cared  for  by  the  doctors  and  nurses  in  these  dispensaries.  All  medical  charts 
for  children  are  kept  at  the  Babies'  Dispensary  or  at  the  prophylactic  dispensary  which 
the  child  attends. 

"Sick  children  who  are  too  ill  to  go  to  the  dispensary  are  attended  by  the  district 
Dhysicians.  The  boarding  women  are  instructed  to  notify  the  district  doctor  of  their  dis- 
:ricts  in  case  of  such  illness.  The  doctor  arranges  for  the  child  to  go  to  the  hospital  if 
lecessary. 

"Children  over  three  years  of  age  when  received  by  the  society  have  medical  examina- 
ions  made  by  the  doctors  at  the  prophylactic  dispensaries,  the  examinations  being  made 
n  the  district  in  which  the  boarding  home  is  located.  Medical  treatment  for  these  chil- 
lren  is  provided  at  the  dispensaries  of  the  various  hospitals.  If  the  children  are  placed 
n  boarding  homes  outside  of  the  city  limits  the  family  physician  of  the  boarding  mother 

*This  description  was  prepared  for  the  Survey  by  the  Director  of  the  Cleveland  Humane  Society. 


178  Hospital  and  Health  Survey 


is  generally  called.     Dental  work  for  these  children  is  done  at  the  Western  Reserve  Uni- 
versity Dental  School,  the  society  paying  for  the  material  used. 

"Supervision — The  nurses  of  the  Division  of  Health  supervise  all  boarding  homes 
within  the  city  limits.  Each  nurse  visits  weekly  the  children  in  boarding  homes  in  her 
respective  district  and  each  week  makes  a  report  of  her  visits  to  the  Division  of  Health. 
A  copy  of  this  report  is  sent  to  the  society.  The  visitors  of  the  society  also  supervise 
children  in  boarding  homes.  The  matters  pertaining  to  the  health  of  the  children,  however, 
are  left  to  the  nurses  and  to  the  dispensaries. 

"Homes — The  children  are  placed  in  family  homes  which  have  been  investigated  by 
the  society  and  licensed  by  the  Division  of  Health.  Applications  for  licenses  are  con- 
sidered by  a  committee  consisting  of  representatives  of  the  Division  of  Health  and  the 
Humane  Society  before  a  recommendation  for  license  is  made  to  the  Board  of  State  Chari- 
ties. It  is  the  policy  of  the  society  not  to  place  more  than  one  child  in  a  home  unless  the 
children  are  related.  The  society  has  five  subsidized  homes,  having  five  beds  in  each  home, 
where  children  are  cared  for  temporarily  while  arrangements  are  being  made  to  place  them 
in  other  boarding  homes.  The  society  has  no  special  homes  for  the  care  of  convalescent 
children  or  diseased  children." 

Suggested  Procedure 

All  activities  relative  to  the  placing  out  of  children  in  foster  homes  should 
radiate  from  a  central  institution  or  place,  which  we  will  tentatively  call  a 
Children's  Placement  Bureau  of  the  Division  of  Health. 

Before  a  child  is  listed  in  the  Children's  Placement  Bureau  an  investiga- 
tion by  the  Humane  Society  should  be  made  to  see  that  the  child  is  one 
requiring,  and  suitable  for,  placement.  It  having  been  decided  that  the 
child  is  to  be  placed  out,  he  is  taken  to  the  Children's  Placement  Bureau, 
and  the  parent  or  legal  guardian  should  sign,  at  that  time,  a  release,  permit- 
ting the  Placement  Bureau  to  relieve,  by  proper  treatment,  physical  condi- 
tions from  which  the  child  may  suffer,  along  the  lines  indicated  below: 

Date 1920. 

I  hereby  agree  and  consent  that  if  my  child,... , 

while  under  the  control  of  the  Children's  Placement  Bureau,  shall  be  found 
to  have: 

1 .  Defective  Vision, 

2.  Defective  Hearing, 

3.  Defective  Teeth, 

4.  Defective  Nasal  Breathing, 

5.  Hypertrophied  Tonsils, 
^                 6.     Orthopedic  Defects, 

these  defects  may  be  corrected  under  the  direction  of  the  authorities  of  said 
Children's  Placement  Bureau,  without  further  action  on  my  part. 

Name 

Address 

Relationship 


Public  Health  Services 


179 


The  child  should  be  kept  under  the  control  of  the  Placement  Bureau 
either  in  its  own  building  or  buildings  or  in  specially  subsidized  homes  until 
these  defects  have  been  corrected,  if  it  is  probable  that  they  can  be  corrected 
within  a  short  period,  say  two  to  four  weeks.  If  a  defect  is  chronic  in  nature, 
the  child  having  the  chronic  defect  should  be  released  to  a  specially  graded 
foster  home,  and  kept  only  in  such  specially  graded  home  until  the  defect 
has  been  corrected.  In  making  recommendation  that  a  child  be  sent  to  a 
specially  graded  foster  home,  unsatisfactory  condition  of  the  teeth  alone 
should^not  ordinarily  be  considered  as  a  chronic  defect. 


SOARD 
L0F  HEALTH/ 


fOISTiRICT1 
[PHYSCIANS/ 


BABIES 
IDJSPENSAKY". 


CHI 


[All   OTHff 
IHOSpiTAlSJ 


:N5 


EMENT, 
EAtf 


/cleveland) 
-Humane 

)CIETY> 


nee 

iDFpAPJf-W 


rOSTER 
HOMES 


original 
Home 


Fig.  XIV. 

While  in  the  Children's  Placement  Bureau,  in  addition  to  the  regular 
physical  examination  which  may  be  made  at  the  Babies'  Dispensary  or  other 
institution,  as  decided  upon  by  the  Children's  Placement  Bureau,  the  chil- 
dren should  be  Schick  tested  and  a  culture  should  be  taken  from  both  nose 
and  throat.  If  the  case  is  suitable,  toxin — antitoxin,  for  immunization- 
should  be  given.     They  should  be  tested  for  tuberculosis  and  Wassermann 


180  Hospital  and  Health  Survey 


test  should  be  made.  In  the  case  of  females,  vaginal  smears  should  be  taken. 
Vaccinations  should  be  done  where  indicated.  No  child  should  be  sent  to 
a  foster  home  while  defects  are  being  corrected,  unless  the  defects  are  of  a 
chronic  nature. 

The  foster  homes  should  be  graded  "A"  and  k'B."  The  "A"  homes  should 
be  those  conducted  by  women  who  have  proved  themselves  to  be  specially 
qualified  to  care  for  children,  und  the  grade  "B"  to  include  all  other  licensed 
homes.  The  foster  mothers  having  grade  "A"  homes  should  receive  the 
children  with  chronic  defects,  and  should  be  paid  a  larger  compensation 
than  those  having  grade  "B"  licenses,  in  view  of  the  fact  that  they  have 
superior  training,  and  that  a  child  with  a  chronic  defect  is  harder  to  manage, 
and  so  the  grade  "A"  foster  mother  is  entitled  to  a  larger  sum. 

By  this  method  any  child  with  a  readily  remediable  defect  would  remain 
in  the  Placement  Bureau  until  in  good  general  health,  and  the  children  with 
chronic  defects  would  receive  special  care  until  their  defects,  if  correctable, 
are  cured.  The  effect  on  foster  mothers  of  having  two  grades  of  license  would 
be  to  spur  the  grade  "B"  foster  mothers  on  to  do  good  work  in  order  that 
they  might  get  a  grade  "A"  license,  with  its  increased  income,  and  those  who 
already  have  a  grade  "A"  license,  to  exert  themselves  in  order  that  they  may 

continue  to  hold  that  grade. 

• 

After  the  children  have  been  placed  in  foster  homes  the  Division  of  Health 
should  supervise  the  home,  and  pay  particular  attention  to  the  sanitary  con- 
dition of  the  home  and  the  health  of  the  foster  mother  and  of  the  children; 
the  Humane  Society  at  the  same  time  making  stated  visits  to  supervise  the 
moral  and  financial  conditions  surrounding  the  child  in  the  boarding  home. 

It  should  be  the  aim  of  the  Central  Placement  Bureau  to  have  as  few 
children  as  possible  in  each  home.  Whenever  the  number  of  children  in  a 
home  exceeds  three  in  number,  whether  subsidized  or  not,  there  should  be, 
in  addition  to  the  preliminary  investigations  made  by  the  Humane  Society 
and  the  Division  of  Health,  an  investigation  of  the  premises  made  by  the 
Fire  Department  to  determine  whether  the  building  is  reasonably  safe  to 
house  the  number  of  children  for  which  a  permit  is  to  be  issued. 

While  the  children  are  under  the  care  of  the  foster  mothers,  they  should 
be  taken  from  time  to  time  to  the  Babies'  Dispensary  or  the  prophylactic 
dispensaries  of  the  Division  of  Health  for  re-examination,  observation, 
regulation  of  diet,  etc.,  and  when  ill  and  unable  to  go  to  the  dispensaries 
should  be  cared  for  by  the  district  physician  or  be  sent  by  him  to  the  ap- 
propriate hospital. 

A  diagram  illustrating  the  contacts  between  the  various  services  as  sug- 
gested above  follows:     Fig.  XIV. 

Day  Nurseries  in  Cleveland 

There  are  seven  day  nurseries  in  Cleveland,  five  of  which,  the  Mather, 
Louise,  Lend-a-Hand,  Perkins  and  Wade,  are  branches  of  the  Cleveland 
Day  Nursey  and  Free  Kindergarten  Association;  one,  Merrick  House,  is 
conducted  in  connection  with  that  Settlement  House;    and  one,  Joseph  & 


Public  Health  Services  181 

Feiss,  is  maintained  by  that  industrial  plant  for  the  children  of  its  employes. 
Three  of  these  day  nurseries,  Louise,  Perkins  and  Wade,  are  in  the  same 
building  with  kindergartens.  Joseph  &  Feiss  are  thinking  of  conducting  a 
kindergarten  during  the  summer,  but  no  definite  plans  have  been  made. 

The  Cleveland  Day  Nursery  and  Free  Kindergarten  Association,  which 
maintains  five  nurseries,  four  kindergartens  and  a  Kindergarten  Training 
School,  is  a  voluntary  organization  included  in  the  Welfare  Federation.  The 
Association  employs  an  executive  secretary,  who  has  charge  of  administra- 
tion and  who  also  acts  on  authority  delegated  by  the  Division  of  Health  as 
the  official  investigator  of  day  nurseries  in  Cleveland. 

At  the  instigation  of  the  Day  Nursery  and  Free  Kindergarten  Association, 
City  Ordinance  No.  47591  was  passed  in  October,  1918,  to  regulate  the  day 
nurseries  in  Cleveland.  This  ordinance  was  based  upon  the  ordinances  in 
New  York  City  and  Chicago  and  its  provisions  for  equipment  and  operation 
of  day  nurseries  are  excellent. 

This  ordinance  makes  specifications  as  to  medical  service  (including 
initial  and  periodic  physical  examinations);  plant  and  equipment;  ventila- 
tion; light;  heat;  air  space  (300  cubic  feet  per  child) ;  playground;  cleanli- 
ness; methods  of  cleaning;  provision  of  individual  beds;  care  of  children's 
clothing;  provision  of  individual  washcloths,  towels,  bed  linen,  combs,  tooth 
brushes,  hairbrushes  and  drinking  cups;  toilet  facilities;  isolation;  food  and 
care  thereof,  and  sanitation,  etc. 

All-day  nurseries  in  Cleveland  must  be  licensed  and  permits  are  issued 
by  the  Commissioner  of  Assessments  and  Licenses  upon  recommendation  of 
the  Commissioner  of  Health,  after  an  investigation  of  the  premises  has  been 
made  by  the  Bureau  of  Child  Hygiene.     These  permits  are  issued  annually. 

The  Division  of  Health  having  no  adequate  personnel  for  supervision  of 
day  nurseries,  delegated  the  authority  for  such  supervision  to  the  executive 
secretary  of  the  Day  Nursery  and  Free  Kindergarten  Association,  who,  be- 
cause of  the  pressure  of  other  duties,  has  little  time  to  spend  in  the  sanitary 
supervision  of  nurseries.  Excellent  results  have  been  accomplished,  how- 
ever, by  the  Day  Nursery  Association  in  suppressing  various  "mushroom" 
nurseries  that  have  sprung  up  from  time  to  time  and  which  did  not  meet  the 
standards  provided  for  in  the  ordinance. 

The  aggregate  attendance  at  the  nurseries  for  1919  was  47,085  child- 
days,  and  the  average  daily  •attendance  of  children  was  184.75.  The  num- 
ber of  rejections  of  applicants  for  nursery  care  from  August,  1919,  to  Janu- 
ary, 1920,  was  131,  of  which  ten  only  were  due  to  lack  of  room  in  the  nur- 
series. 

The  Day  Nursery  Association  formerly  had  an  investigator  to  pass  on  all 
admissions  as  to  social  or  economic  necessity  of  providing  care  for  the  child. 
Now  admissions  are  made  by  the  superintendents. 

Children  who  have  only  one  parent,  usually  a  widowed  or  deserted 
mother,  are  admitted  to  the  day  nurseries.  In  rare  instances  children  with 
two  parents  are  cared  for  if  the  father  is  ill  or  incapacitated.     In  some  cases 


182  Hospital  and  Health  Survey 

children  are  admitted  when  the  mother  goes  to  work  as  well  as  the  father. 
The  age  of  admission  is  from  six  months  to  fourteen  years,  nursing  children 
being  admitted  only  on  special  recommendation  of  the  examining  physician. 
At  the  time  this  investigation  was  made  very  few  nursing  children  were  regis- 
tered in  the  nurseries. 

If  the  economic  status  of  the  family  warrants,  a  charge  of  fifty  cents  per 
day  is  made.  The  estimated  cost  per  day  for  each  child  to  the  Day  Nur- 
sery Association  is  about  $1.00. 

A  study  of  the  admission  procedure  at  the  day  nurseries  and  of  the  eco- 
nomic question  involved  in  providing  day  nurseries  for  the  care  of  children 
of  women  in  industry,  will  be  made  by  the  Welfare  Federation  in  connection 
with  their  study  of  children's  institutions. 

Medical  Service 

The  Day  Nursery  and  Free  Kindergarten  Association  employs  a  physi- 
cian on  part  time  to  give  medical  service  to  the  five  day  nurseries  under  its 
care.  Before  being  admitted  to  the  nursery,  the  children  receive  a  physical 
examination  either  by  the  day  nursery  physician  or  at  a  nearby  dispensary. 
The  examination  consists  of  the  following: 

History  of — Chickenpox,  measles,  mumps,  scarlet  fever,  whooping  cough, 
vaccination. 

Examination  of — Glands,  skin,  eyes,  ears,  nose,  teeth,  throat,  tonsils, 
heart,  lungs,  abdomen  and  weight.  The  examiner  gives  special  attention  to 
the  nutrition  and  development  of  the  child,  and  looks  for  any  evidences  of 
anemia. 

This  examination  is  made  with  the  children's  clothes  loosened  or  removed. 

No  laboratory  tests  are  made  at  the  day  nurseries,  but  any  such  necessary 
work  is  referred  to  the  various  dispensaries  or  to  the  Division  of  Health.  No 
diphtheria  culture  tubes  are  kept  at  the  nurseries,  the  physician  having[a 
supply  of  these  with  him  when  calling  at  the  nurseries^ 

'  Each  superintendent  interviewed  stated  that  there  was  a  daily  inspection 
of  the  children  on  admission,  either  by  herself  or  by  a  nurse,  for  symptoms 
of  contagious  disease. 

The  last  sentence  of  regulation  21,  "each  child  admitted  to  or  cared  for 
in  any  day  nursery  shall  be  examined  at  least  once  every  three  months," 
did  not  seem  to  be  thoroughly  understood  or  adequately  carried  out  by  the 
day  nurseries.  No  superintendent  interviewed  stated  that  there  was  a 
periodical  re-examination  of  children  every  three  months,  and  a  number  of 
cards  of  children  who  had  been  in  the  nurseries  four  months  and  over,  did 
not  show  any  record  of  re-examinations.  Children  who  have  been  absent 
from  the  nursery  for  a  week  or  more  are  examined  either  by  the  nursery 
physician  or  at  a  nearby  dispensary  before  readmission. 


Public  Health  Services  183 

The  children  in*  the  nurseries  are  weighed  either  every  two  weeks  or 
every  month,  the  procedure  varying  in  the  different  nurseries.  Excellent 
weight  charts  are  kept.  Opposite  each  child's  name  a  star  is  placed,  a  blue 
star  indicating  loss  or  stationary  weight,  and  a  red  star  a  gain.  These  charts 
have  proved  of  great  educational  value  to  both  mothers  and  children. 

Two  of  the  nurseries  have  trained  nurses  as  superintendents.  For  nurs- 
ing service  the  other  nurseries  can  avail  themselves  of  the  service  of  the 
nurses  of  the  Division  of  Health  or  of  the  Visiting  Nurse  Association,  but  the 
superintendents  do  not  seem  to  be  taking  advantage  of  these  opportunities 
as  fully  as  could  be  desired. 

The  follow-up  to  correct  defects  is  carried  on  under  the  direction  of  the 
superintendents.  A  study  of  the  records  of  the  five  day  nurseries  under  the 
control  of  the  association  gives  the  following  results:  of  197  children  who 
had  been  under  the  care  of  the  day  nurseries  over  four  months,  there  were 
four  cases  of  defective  vision,  three  of  which  had  been  corrected  and  one  of 
which  was  under  parental  care.  There  were  eighty  cases  of  defective  teeth, 
on  which  fifty-two,  or  65  per  cent,  of  the  corrections  had  been  made.  Be- 
sides these  corrections  one  case  was  under  parental  care  and  three  were  over 
school  age.  Sixty-six  cases  of  diseased  or  hypertrophied  tonsils  were  noted, 
of  which  forty-one,  or  62.1.  per  cent,  had  been  corrected.  Also  there  were 
three  under  parental  care,  one  "unwilling"  and  one  "improved."  According 
to  these  figures  which  were  furnished  by  the  Day  Nursery  Association,  the 
follow-up  work  of  the  nurseries  seems  to  be  adequate. 

Vaccinations  are  made  by  the  nursery  physician  on  all  children  who  have 
not  been  vaccinated. 

Merrick  House: 

The  medical  service  at  Merrick  House  is  practically  the  same  as  that 
furnished  to  the  nurseries  under  the  Day  Nursery  Association,  with  the  ex- 
ception that  the  physician  visits  twice  a  week. 

Joseph  &  Feiss: 

The  medical  service  is  given  by  the  physician  in  charge  of  the  factory, 
who  is  on  call  at  any  time  and  who  always  responds  quickly.  According  to 
the  facts  furnished  by  the  superintendent,  the  service  given  comes  up  to  the 
standards  of  the  ordinance.  The  children  are  examined  on  admission,  re- 
examined after  absence,  etc.  The  superintendent  of  the  nursery  is  a  trained 
nurse. 


184  Hospital  and  Health  Survey 

Summary  of  Conditions  Found  in  the  Seven  Nurseries  by  the 

Investigator 

Number  of 
Nurseries 

Sleeping  room  not  provided  with  the  minimum  cubic  air  capacity  required 

by  the  city  ordinance 2- 

Children  sleeping  together.... _ L 1 

Drinking  cups  used  in  common _ _. 4 

Combs  used  in  common  or  incompletely  sterilized  after  use 5 

No  ventilation  in  room  in  which  children  were  playing 2 

Poor  ventilation  of  toilets . 2 

Dry  dusting  and  sweeping  done..... 4 

Clothing  hung  too  closely  to  permit  of  clothing  ventilation... 2 

Wash  cloths,  towels  and  tooth  brushes  hung  so  closely  that  in  some  in- 
stances they  touched 4 

Beds  not  identified 2 

Aprons  not  identified 1 

Bibs  not  identified  and  piled  together  after  each  use. 1 

Rubber  sheets  not  provided  for  all  beds  of  infants 1 1 

RECOMMEND  A  TIONS 

1.  Supervision: 

That  the  responsibility  for  the  enforcement  of  the  requirements  of  the  day  nursery 
ordinance  be  assumed  by  the  Division  of  Health,  and  inspection  of  the  day  nurseries  be 
made  by  a  trained  inspector  under  the  Bureau  of  Child  Hygiene  in  the  Division  of  Health. 

That  monthly  inspections  of  the  day  nurseries  be  made. 

That  the  provisions  of  the  city  ordinance  in  regard  to  individual  beds,  isolation  rooms, 
adequate  ventilation  and  air  space  and  other  necessities  for  satisfactory  sanitation  in  the 
day  nurseries,  which  are  violated  at  the  present  time,  be  observed  and  enforced. 

2.  Medical  and  Nursing  Service: 

That  the  regulation  which  has  produced  good  results  in  other  cities  and  which  requires 
a  vaginal  smear  of  all  girls  before  admission,  might  be  found  of  value  in  giving  additional 
protection  against  infection. 

That  there  be  an  increase  of  the  home  nursing  service  given  to  the  children  attending 
the  day  nurseries  and  that,  for  this  service,  the  day  nurseries  call  upon  the  Division  of 
Health  or  the  Visiting  Nurse  Association  nurses  in  the  district. 

3.  General: 

That  a  further  study  into  the  admission  procedure  and  organization  of  day  nurseries 
be  made  by  the  Welfare  Federation  in  connection  with  their  study  of  children's  institu- 
tions. In  this  investigation  special  attention  should  be  given  to  the  economic  question 
involved  in  providing  day  nursery  care  for  the  children  of  women  in  industry. 


Public  Health  Services  185 


From  the  numerous  defects  of  equipment  and  management  and  professional  services 
discovered,  among  the  institutions,  homes  and  nurseries  above  described,  and  from  the 
serious  extent,  to  which  physical  defects  prevail  among  the  dependent  children  examined 
it  would  appear  plain  that  all  precautions  for  these  otherwise  helpless  public  wards  are 
not  being  taken  for  their  present  and  future  health. 

It  is  recommended  that  institutional  inspection  be  recognized  as  a  legitimate  activity 
of  the  Division  of  Health  and  that  an  organization  adequate  to  look  after  the  institutions 
and  homes  for  children  be  created  there. 

INDUSTRIAL  HYGIENE 

Although  the  complete  argument  for  better  protection  of  industrial 
workers,  based  on  an  extensive  study  of  the  existing  conditions  in  industrv 
in  Cleveland,  will  be  found  in  Part  VII.  of  this  report  it  is  worth  noting  here 
that  whatever  may  be  done  voluntarily  and  in  response  to  the  human  and 
economic  interests  of  individual  employers  and  corporations,  there  will 
surely  be  industries  and  individual  plants  where  only  so  much  is  done  for 
the  health  and  sanitary  safety  of  the  employes  as  labor  organizations  and 
officers  of  public  departments  force  the  employers  to  do.  Even  in  the  brief 
period  of  the  Survey  a  number  of  instances  of  flagrant  violation  of  human 
health  rights  in  Cleveland  industries  came  to  notice,  which  could  not  have 
endured  and  should  not  have  developed  at  all  if  it  were  known  that  capable 
inspection  and  swift  action  were  ready  for  the  protection  of  employes. 

Not  only  are  the  employes  but  the  employers  entitled  to  the  kind  of 
guidance  which  those  trained  in  the  science  of  industrial  hygiene  can  give 
them,  in  the  manner  of  using  human  labor  so  that  undue  risks  and  perma- 
nent health  liability  may  not  be  incurred. 

It  is  recommended  that  a  bureau  or  sub-division  of  an  existing  bureau 
be  established  to  detect  and  correct  health  hazards  in  industry.  If  there 
were  a  trained  sanitarian  at  the  head  of  the  bureau  of  sanitation,  industrial 
hygiene  might. at  first  be  included  there,  but  it  is  believed  that  a  separate 
bureau  for  this  purpose  should  be  created  with  a  chief  trained  in  the  investi- 
gation and  remedy  of  injurious  processes  and  conditions  affecting  industrial 
employes. 

MEDICAL  EXAMINATION   FOR   CITY  EMPLOYES 

The  city  of  Cleveland  employs  more  people  than  any  organization  of 
industry  or  commerce  within  the  city  or  near  it.  The  city  payroll  varies 
from  6,500  in  winter  to  8,000  in  summer.  This  varied  personnel  is  entirely 
without  any  organized  medical  service.  In  a  few  departments  physical  ex- 
amination may  or  may  not  be  offered  or  required  at  the  time  of  employment, 
but  most  of  the  city  employes  enter  public  service  without  any  medical 
observation  as  to  fitness  for  their  work.  In  a  few  departments  medical  care 
is  available  in  case  of  sickness.  In  no  department  is  there  an  annual  medi- 
cal survey  and  examination  of  each  employe. 

From  records  of  many  thousands  of  examinations  throughout  this  coun- 
try we  can  prophesy  that  from  130  to  160  (i.  e.,  2%)  of  the  city  employes 


186  Hospital  and  Health  Survey 


have  active  pulmonary  tuberculosis  and  that  most  of  them  are  unaware  of  it 
until  too  late;  from  4,850  to  6,000  (i.e.,  75%)  are  in  need  of  medical  or 
dental  advice  or  treatment  for  serious  or  minor  defects  and  diseases,  most 
of  which  (64%)  could  be  prevented  or  permanent  damage  avoided  by  early 
recognition. 

It  is  recommended  that: 

The  Division  of  Health  be  authorized  to  employ  physicians  and  organize  a  service  for 
the  medical  examination  of  all  applicants  or  appointees  to  positions  in  the  city  service 
and  for  an  annual  re-examination  of  every  one  on  the  city  payroll  from  the  mayor  down. 

Provision  be  made  for  the  privacy  of  records. 

Treatment  for  defects  be  not  undertaken  at  present  as  a  charge  upon  the  taxpayer. 

If  there  were  to  be  one  service  established  by  the  city  in  the  interest  of 
health  protection  it  is  believed  that  that  should  be  free  diagnostic  service: 
that  is,  medical  examination  of  the  apparently  healthy  of  all  ages  and  con- 
ditions of  the  people.  Prevention  of  disease  depends  on  its  recognition. 
Medical  practice  for  treatment  of  diseases  alone  will  never  meet  the  needs. 
What  we  need  in  the  interest  of  public  welfare  is  a  universal  habit  of  applying 
once  a  year  to  a  physician  so  that  he  may  serve  his  most  important  function; 
namely,  match  his  diagnostic  skill  against  the  insidious  evidences  of  impaired 
structure  and  function  in  man.  The  administration  and  provision  of  medical 
services  by  the  city,  free  to  all  who  can  be  taught  to  apply,  would  be  the  best 
health  investment  the  city  could  make  and  nothing  would  so  stimulate 
physicians  to  the  best  they  are  capable  of. 

Private  patients  should  now  establish  the  practice  of  calling  in  their 
family  physician  for  a  health  examination  annually,  and  should  learn  from 
him  what  they  may  expect  or  what  they  must  do  to  preserve  or  attain  health. 
For  infants  and  school  children  such  services  are  developing  but  are  not  yet 
complete.  For  industries  such  services  are  becoming  the  rule.  The  custom 
should  become  universal. 

PUBLIC  HEALTH  EDUCATION 

At  the  beginning  of  the  chapter  on  Public  Health  Services  reference  is 
made  to  the  unfortunate  lack  of  such  a  necessary  public  service  as  was  evi- 
dently conceived  by  the  framers  of  the  city  charter  when  they  provided  for 
a  Commissioner  of  Research  and  Publicity  within  the  Department  of  Public 
Welfare. 

In  order  to  picture  more  concretely  the  present  assets  of  Cleveland  in 
this  field  a  brief  report  of  existing  health  education  resources  in  Cleveland 
has  been  prepared. 

It  would  be  difficult,  indeed,  to  make  a  comprehensive  summary  of 
public  health  education  in  Cleveland  for,  undoubtedly,  all  social  agencies 
and  agents  strive— whenever  an  opening  is  presented — to  inform  their  bene- 
ficiaries in  regard  to  health  rules  and  their  observance.  Only  the  principal 
channels  through  which  this  kind  of  education  is  directed  will  be  mentioned. 


Public  Health  Services  187 

The  primary  sources  of  health  information  are,  of  course,  the  practitioners 
of  medicine  and  the  nurses  who  see  all  classes  of  people  and  all  types  of 
disease. 

Of  the  private  agencies  those  which  offer  nursing  service  probably  have 
the  best  chance  of  bringing  home,  with  telling  effect,  their  lessons  in  health 
education.  The  contacts  of  the  nurses  from  the  Visiting  Nurse  Association 
and  the  University  District  are  with  families  where  there  is  sickness  and  their 
opportunities  for  instruction  along  health  lines  are  only  limited  by  the  num- 
ber of  cases  under  their  care.  Nurses  of  the  prenatal  stations  of  Maternity 
Hospital  and  the  nurses  of  the  Babies'  Dispensary  and  Hospital  carry  the 
"word"  on  special  health  topics  (hygiene  of  pregnancy  and  care  of  the  sick 
child)  to  mothers  and  prospective  mothers.  During  the  summer  months 
the  field  of  influence  of  the  Babies'  Dispensary  and  Hospital  is  considerably 
widened  by  the  operation  of  the  Babies'  Special.  This  is  an  automobile 
clinic  which  tours  the  outlying  districts  and  rural  communities  of  the  county. 
The  doctor  and  nurse  in  attendance  give  demonstrations  and  advice  upon 
the  care  of  the  babies. 

The  social  service  workers  at  the  hospitals  (Charity,  Lakeside  and  Mount 
Sinai)  and  the  field  agents  of  the  Associated  Charities  are  also  important 
factors  in  the  attempt  to  make  the  knowledge  of  health  principles  universal. 
Whenever  the  Associated  Charities'  visitors  find  a  health  problem  in  a  home 
they  make  every  effort  to  cooperate  with  the  nurses  of  the  Visiting  Nurse 
Association  or  of  the  Health  Centers  in  promoting  good  health  standards  and 
in  following  up  medical  care.  These  agents  also  act  as  distributors  of  health 
literature  when  it  is  provided  by  the  Division  of  Health. 

A  private  agency  which  is  bringing  the  message  of  health  to  large  num- 
bers of  women  and  girls  is  the  Red  Cross.  Through  the  Teaching  Center, 
courses  in  prophylaxis,  home  care  of  the  sick  and  first  aid  to  the  injured, 
ire  offered.  Courses,  consisting  of  17  to  20  talks  with  demonstrations,  are 
*iven  by  the  nurses  at  the  Center  and  in  factories,  schools,  settlements, 
department  stores  and  churches. 

The  Anti-Tuberculosis  League,  in  trying  to  increase  the  knowledge  of 
tnti-tuberculosis  measures,  assists  by  its  literature  and  lectures  in  spread- 
ng  the  gospel  of  good  health. 

The  clubs  at  the  settlement  houses  (Alta  House,  Council  Educational 
Alliance  and  Goodrich  House)  and  at  the  Y.  M.  C.  A.  offer  an  opportunity 
or  instructing  young  men  and  women  in  social  hygiene  and  tuberculosis 
prevention.  At  the  Y.  M.  C.  A.  it  is  estimated  that  1,000  men  are  reached 
n  this  way  each  month.  At  the  Central  Friendly  Inn  and  the  Y.  W.  C.  A. 
ealth  and  home  hygiene  courses  are  arranged  to  supplement  the  domestic 
cience  courses.  Hiram  House  last  fall,  in  its  Boys'  Department,  had  a 
Health  Week"  and  carried  on,  through  lectures,  demonstrations  and  litera- 
ure,  a  health  campaign.  The  Boy  Scouts,  the  Girl  Scouts  and  the  Camp- 
re  Girls,  by  a  system  of  awards,  put  a  premium  on  good  health. 

The  public  agencies  interested  in  educating  the  masses  along  health  lines 
re  the  Division  of  Health,  the  Board  of  Education  and  the  Public  Librarv. 


188  Hospital  and  Health  Survey 

This  work  is  done  by  the  Division  of  Health  through  the  doctors  and  nurses 
at  the  Health  Centers  and  through  the  nurses  in  the  homes.  Instruction 
and  advice  are  given  on  how  to  keep  well  babies  well,  on  tuberculosis  control 
and  on  care  and  prevention  of  contagious  diseases. 

At  the  present  time  health  education  is  carried  on  under  the  Board  of 

Education  in  the  following  ways: 

1.  Through    occasional    classroom    talks    on    health    topics    given    by- 
nurses  of  the  Department  of  School  Medical  Inspection. 

2.  Through  individual  instruction  of  the  children  in  the  schools  by 
physicians  and  nurses  of  the  Department  of  School  Medical  Inspection. 

3.  Through  instruction  by  the  nurses  to  girls  in  the  seventh  and  eighth 
grades,  on  the  subject  of  care  of  babies. 

4.  Through  two  forty-minute  periods  a  week  in  physiology  and  hygiene 
in  the  grammar  grades. 

5.  Through  physical  training  in  the  high  schools  and  elective  courses  in 
physiology,  botany,  cooking,  chemistry  and  social  problems. 

In  practice  little  or  no  work  in  hygiene  is  carried  out  in  the  elementary 
schools.  In  the  Junior  High  grades  an  outline  has  been  provided  but  the 
teachers  are  not  obliged  to  follow  it.  In  the  high  schools  the  courses  in  health 
education  are  not  standardized  and  it  is  difficult  to  tell  how  much  overlap- 
ping of  courses  exists.     There  is  need  for  a  standardized  syllabus. 

The  Public  Library,  through  its  Information  Bureau,  suggests  books  to 
be  consulted  for  light  on  health  matters. 

From  this  resume  it  is  evident  that  health  education  is  carried  on  quite 
extensively  in  Cleveland,  but  there  is  need  for  an  organized  and  intensive 
health  program.  The  Survey  is  entirely  in  sympathy  with  the  views  of  the 
International  Red  Cross,  as  expressed  at  the  Cannes  conference  in  1919. 

"We  are  convinced  of  the  prime  importance  of  widely  disseminating  among  the  people 
a  knowledge  of  the  simple  laws  of  healthful  living  and  a  conviction  as  to  the  need  of  apply- 
ing them.  This  is  the  most  valuable  means  whereby  we  can  promote  their  physical  well- 
being;  and,  with  a  'health  conscience'  formed,  most  public  health  problems  become 
simplified  and  all  public  health  administration  is  made  more  easy. 

"It  may  be  said  that  the  measure  of  the  public  health  of  any  community  is  in  no  small 
degree  the  measure  of  self-help  in  health  matters.  Official  and  voluntary  health  agencies 
can  effect  much  in  the  direction  of  improving  the  environment  of  the  individual  and  pre- 
venting communicable  diseases;  relatively  they  can  effect  little  in  the  direction  of  securing 
hygienic  observances  in  the  intimate  circumstances  of  living,  and  in  the  wider  field  of  non- 
communicable  but  preventable  disease.  Ignorance  and  carelessness  are  here  responsible 
for  much  sickness  and  premature  death. 

"It  is  largely  because  child  welfare  work  is  essentially  educational  that  so  much  suc- 
cess is  obtained  in  it;  and  we  consider  that,  profiting  from  this  experience,  public  educa- 
tion should  be  made  a  prominent  part  of  public  health  activities  in  every  field  of  work. 


Public  Health  Services  189 


"Hygienic  precepts  and  practice,  and  the  training  of  the  older  girls  in  the  essentials 
of  infant  care  and  home-making  are  of  fundamental  importance  as  a  means  of  contribut- 
ing greatly  to  the  health  and  happiness  of  a  community.  For  those  who  have  left  school 
an  active  educational  propaganda  should  be  maintained.  For  popular  propaganda  pur- 
poses we  would  indicate  the  following  as  agencies  of  proved  value : 

1.  The  Public  Press. 

2.  Cinema  Films. 

3.  Posters. 

4.  Exhibits. 

5.  Popular  Lectures. 

6.  Educational  campaigns  on  special  health  topics  in  which  all  these  agen- 
cies are  employed. 

"We  consider  that  for  most  effective  propaganda  assistance  is  generally  necessary 
from  experts  in  publicity  matters." 

RECOMMEND  A  TIONS 

1.  It  is  recommended  that  the  Board  of  Education  organize  consistent  education  in 
health  through  the  entire  school  course  of  the  child.  The  board  should  accept  the  services 
of  the  Red  Cross  Teaching  Center  to  carry  on  this  work  until  such  time  as  appropriations 
can  be  made  for  the  purpose. 

2.  It  is  recommended  that  there  be  a  bureau  of  public  health  education  in  the  Divi- 
sion of  Health,  with  a  full-time  publicity  expert  in  charge,  to  carry  on  the  activities  out- 
lined above  and  to  coordinate  all  efforts  of  the  various  private  agencies,  or  that  a  full-time 
publicity  expert  be  employed  by  the  proposed  Public  Health  Association  or  by  the  Anti- 
Tuberculosis  League. 

CONTROL  OF  DRUG  ADDICTION 

Medical  service  and  correctional  interests  are  so  involved  in  the  control 
and  care  of  drug  addicts  that  there  must  be  effective  cooperation  between 
the  Division  of  Health  and  the  Police  Department  in  handling  the  matter. 

The  city  police  must  assist  the  federal  revenue  officers  in  blocking  the 
illegal  channels  of  distribution  of  the  narcotic  drugs  and  in  confining  the  sup- 
ply and  distribution  of  the  drugs  to  the  hands  of  licensed  pharmacists,  physi- 
cians, veterinarians  and  dentists. 

The  Division  of  Health  must  take  part  in  the  supervision  of  the  addicts 
until  they  are  cured  or  are  accommodated  in  institutions  where  they  can  be 
freed  from  their  affliction  and  rehabilitated  physically. 

Dispensary  and  ambulatory  care  for  drug  addicts  are  futile.  These  pa- 
tients must  be  put  in  institutions  where  their  insane  ingenuity  cannot  avail 
them  in  obtaining  drugs  for  the  continuance  of  their  habit. 

To  quote  from  a  statement  of  the  Commissioner  of  Health: 


190  Hospital  and  Health^Survey 

"City  ordinance  No.  48247-B  places  the  administration  of  narcotic  drugs  in  Cleveland 
as  well  as  the  presenting,  bartering,  selling  or  giving  of  such  drugs  under  the  control  of 
the  Health  Division.  The  enforcement  of  this  ordinance  in  detail  would  require  the  fol- 
lowing organization: 

1  Chief  Inspector, 

2  Inspectors, 
1  Clerk, 

1  Physician. 

"The  work  of  the  inspectors  would  require  a  continuous  inspection  of  the  records  and 
stock  of  narcotic  drugs  in  the  possession  of  those  authorized  to  deal  in  the  same :  namely, 
wholesale  and  retail  drug  houses,  hospitals,  physicians,  dentists  and  veterinarians.  A 
physician  is  required  to  deal  with  those  drug  addicts  who  continually  infest  the  city.  Since 
1918  the  clinic  in  the  City  Hall  has  been  maintained  in  charge  of  one  of  the  district  physi- 
cians assigned  to  the  sub-division  of  Communicable  Disease.  This  clinic  is  financially 
self-sustaining,  as  all  addicts  are  required  to  pay  for  their  treatment  while  in  attendance 
upon  the  clinic.  However,  the  necessity  of  assigning  to  this  work  one  or  more  full-time 
employes  of  the  Health  Division  has  not  yet  been  offset  by  increasing  the  number  of  em- 
ployes allowed  the  Division  under  the  existing  salary  resolution.  It  should  be  stated  that 
no  request  for  additional  employes  to  deal  with  the  addict  problem  has  heretofore  been 
made.  The  city  ordinance  referred  to  above  was  only  passed  in  April,  1919,  and  until 
then  the  handling  of  this  problem  by  the  Health  Division  had  been  considered  as  a  tempo- 
rary matter,  only  to  require  the  services  of  employes  for  a  short  period.  The  outlook  is 
now  entirely  different,  and  a  permanent  organization  to  have  charge  of  the  enforcement 
of  ordinance  No.  48247-B  should  be  set  up." 

The  recommendation  of  the  Commissioner  of  Health  in  this  matter  is 
heartily  endorsed.  If  all  the  additions  and  improvements  of  service  recom- 
mended in  the  foregoing  consideration  of  bureaus  existing  and  proposed  in 
the  Division  of  Health  were  approved  and  appropriations  made,  Cleveland 
would  not  be  spending  more  per  capita  per  annum  than  many  cities  in  the 
country  now  consider  reasonable  for  public  health  services. 

HEALTH  CENTERS 

Centralized  control  and  distributed  services  permit  of  sound  public  health 
organization,  and  the  principle  of  health  centers  upon  which  the  bureaus  of 
child  hygiene  and  communicable  diseases  depend  for  their  district  work  is 
good.  The  health  centers,  as  at  present  operated,  are  little  more  than  dis- 
trict offices. 

It  is  recommended  that  these  centers  be  increased  to  sixteen,  to  permit 
of  one  for  each  50,000  of  the  population  and  that  as  rapidly  as  is  found 
practicable  other  functions  be  added  to  those  now  served  at  the  centers. 
Until  health  centers  serving  as  administrative  branch  offices  of  public  depart- 
ments include  as  well  all  the  services  or  representatives  of  them  which  are 
now  contributed  by  private  agencies  in  the  interest  of  preventive  medicine, 
and  are  operated  in  intimate  organic,  if  not  physical,  connection  with  hos- 
pitals and  dispensaries,  they  will  not  have  met  their  obligations  and  possi- 
bilities of  public  usefulness. 


Public  Health  Services  191 

PUBLIC  SCHOOL  MEDICAL  SERVICE 

The  Board  of  Education  administers  through  school  education  and  its 
medical  services  to  children,  public  health  services  of  inestimable  value.  A 
complete  description  of  this  division  of  public  service  will  be  found  in  Part  III. 

THE  CORONER  SYSTEM 

The  coroner  system  is  in  a  way  a  kind  of  public  health  service,  as  in  its 
conception  it  is  created  to  protect  life  by  determining  accurately  the  causes 
and  conditions  which  have  brought  about  sudden,  violent  or  unexplained 
deaths,  especially  when  the  deceased  had  not  been  under  the  recent  care  of 
a  physician. 

As  long  as  a  coroner  is  elected  or  appointed  in  payment  of  party  political 
debts,  and  as  long  as  the  coroner  selects  his  medical  examiner  or  assistant 
more  with  a  view  to  political  availability  than  as  a  recognition  of  his  merit, 
skill  and  experience  in  pathology  and  forensic  medicine,  our  cities,  and  among 
them  Cleveland,  will  continue  to  be  ill  served  in  this  respect. 

Opportunity  for  "graft"  is  always  present,  and  offering  powerful  tempta- 
tions to  avoid  thorough  search  into  causes  of  death.  The  coroner's  physician 
is  practically  powerless  to  protect  the  public  against  crime.  There  is  every 
opportunity  under  the  present  system  to  cover  up  crime  and  miss  important 
causes  of  preventable  deaths. 

There  is  nothing  to  be  said  in  favor  of  the  coroner,  his  office,  his  medical 
functions  or  the  value  of  his  mediaeval  and  hollow  legal  functions. 

Boston  and  New  York  have  solved  the  difficulty  in  the  only  reasonable 
way,  by  abolishing  the  office  and  creating  the  civil  service  appointive  office 
of  medical  examiner.  The  results  have  been  a  striking  improvement  in  the 
interest  of  honesty,  scientific  accuracy  and  in  the  field  of  health  protection. 
Cleveland  could  not  do  better  than  follow  their  example. 

It  is  so  recommended. 


Private  Health  Agencies 

THE  extent  of  private  endeavor  in  the  field  of  preventive  medicine  is 
hardly  appreciated  until  the  whole  range  of  unofficial  agencies  is  pre- 
sented. We  shall  not  consider  here  the  activities  of  the  national  volun- 
teer health  agencies  even  though  they  may  contribute  a  definite  share  to  the 
work  in  their  respective  fields  in  Cleveland,  but  confine  the  following  brief 
summary  to  local  organizations: 

The  Anti-Tuberculosis  League 

For  a  description  of  the  activities  of  the  Cleveland  Anti-Tuberculosis 
League  the  reader  is  referred  to  Part  IV.,  where  its  accomplishments  and 
recommendations  for  further  extension  of  its  admirable  work  are  presented 
at  some  length. 

The  Visiting  Nurse  Association 

For  a  consideration  of  the  work  of  the  Visiting  Nurse  Association,  one  of 
Cleveland's  remarkable  public  health  assets,  the  reader  is  referred  to  Part 
IX.,  where  the  extensive  project  of  prenatal  and  maternity  nursing  care  is 
proposed  as  a  new  undertaking  for  this  association. 

The  Day  Nursery  and  Free  Kindergarten  Association 

A  description  of  the  functions  of  the  Day  Nursery  and  Free  Kindergarten 
Association  will  be  found  in  the  report  on  this  and  other  child-caring  organ- 
ization in  this  part  of  the  report. 

The  Association  for  the  Crippled  and  Disabled 

The  affiliation  of  all  the  agencies  dealing  with  the  medical  and  social 
problems  of  the  cripple,  in  the  Association  for  the  Crippled  and  Disabled 
has  brought  large  benefits  to  these  handicapped  people,  little  and  big,  and 
this  association  is  certain  to  play  a  part  of  increasing  importance  in  the 
future  program  for  preventive  and  curative  orthopedics  in  Cleveland.  This 
is  dealt  with  in  detail  in  the  chapter  devoted  to  the  Care  of  Cripples  in  this 
part. 

The  Cleveland  Hospital  Council 

The  Hospital  Council,  in  which  originated  the  idea  of  the  present  Survey, 
has  a  record  of  important  contributions  to  local  and  national  hospital  stand- 
ards, economies  and  organization.     It  is  described  in  Part  X. 

The  Cleveland  Society  for  the  Blind 

The  Cleveland  Society  for  the  Blind  has  been  active  for  many  years  and 
carries  on  its  books  the  records  of  545  people  not  in  institutions  who  are 
known  to  be  either  totally  blind  or  to  be  suffering  from  such  a  loss  of  sight 
as  to  make  them  dependent  on  others  for  care  or  support.  This  list  includes 
all  ages  and  both  sexes. 

Of  the  545  blind  people,  the  cause  of  blindness  comes  within  the  list  of 
Preventable  Diseases,  Injuries  or  Infections  in  306  instances  as  follows: 


194 


Hospital  and  Health  Survey 


PREVENTABLE  CAUSES 


Communicable: 

Syphilis....... 40 

Gonorrheal  ophthalmia 32 

Trachoma 16 

Scarlet  fever 13 

Measles 12 

Meningitis 9 

Tuberculosis 3 

Smallpox. 4 

Diphtheria 2 

Poliomyelitis 2 

Ophthalmia  (undetermined  infection)....     6 

Communicable 139 

Injuries 67 

Miscellaneous 100 


Injuries: 

Industrial 21 

Non-Industrial 46 

67 
Miscellaneous: 

Iridocyclitis 1 2 

Choroiditis 1 5 

Keratitis,  interstitial.... 4 

Corneal  opacity 12 

Optic  atrophy 51 

Vitreous  hemorrhage    1 

Irregular  astigmatism 1 

Strabismus 1 

Diabetes 2 

Nephritis 1 


Total 306 


100 


The  blindness  of  the  other  239  instances  was  due  to  causes  which  are 
considered  non-preventable,  as  follows: 


Curable: 

Cataract Ill 

Congenital  cataract 10 

121 
Miscellaneo  us: 

Detached  retina 1 

Orbital  tumor 1 

Sarcoma 2 

Ptosis 1 

Retinitis  Pigmentosa 9 

Glaucoma j 28 

High  Myopia 11 

Optic  atrophy  (brain  tumor) 3 


56 


Not  Sufficient  Diagnosis: 

Congenital 55 

Sunstroke 2 

Insane 1 

Eye  strain 1 

Nervous  prostration 2 

Chorea 1 

62 

Curable... 121 

Miscellaneous 56 

Not  sufficient  diagnosis 62 

Total 239 


Diagnosis  as  to  the  cause  of  blindness  was  not  obtained  for  16  inmates  at 
Warrens ville  Infirmary  and  10  inmates  of  a  Home  maintained  by  the  Little 
Sisters  of  the  Poor. 

According  to  the  very  careful  survey  recently  made  by  the  Massachusetts 
Commission  for  the  Blind,  there  are  probably  in  any  general  population  in 
the  eastern  industrial  communities  one  blind  person  for  each  1,000  people. 
This  would  lead  one  to  expect  a  total  of  a  little  less  than  800  in  Cleveland, 
including  those  in  institutions.     Cleveland  shares  the  experience  of  Massa- 


Private  Health  Agencies  195 

chusetts  in  that  a  constantly  decreasing  number  of  the  blind  are  found  in  the 
age  group  under  five  years,  as  a  result  of  intensive  campaigns  to  prevent  and 
cure  babies'  sore  eyes. 

In  a  city  drawing  its  population  so  widely  from  both  native  and  foreign 
groups  and  tempting  labor  from  parts  of  our  Southern  states  where  trachoma 
is  prevalent,  and  recalling  the  fact  that  in  Ohio  in  one  county  (Ross)  at  least 
1%  of  all  school  children  were  found  recently  to  be  affected  with  trachoma, 
adequate  provision  for  control  of  this  disease  and  prevention  or  correction 
of  the  damage  done  by  it  among  children  and  adults,  must  be  made  by  the 
Board  of  Education,  the  Division  of  Health  and  by  the  clinics  and  hospitals 
of  the  city. 

The  field  of  prevention  of  diseases  of  the  eye  is  not  entirely  filled  by  the 
activities  or  program  of  the  Society  for  the  Blind  and  it  is  recommended  that 
they  adopt  a  more  aggressive  policy  so  that  the  broad  field  of  education  and 
action  and  supervision  proposed  by  the  National  Committee  for  the  Preven- 
tion of  Blindness  may  be  well  cultivated. 

It  is  suggested  that  the  society  enlist  more  active  interest  among  the 
specialists  in  this  field,  in  private  practice  and  in  industry. 

There  has  been  prepared  for  the  Survey,  through  the  courtesy  of  the 
National  Committee  for  the  Prevention  of  Blindness  a  program  covering  all 
aspects  of  this  subject  suitable  for  adoption  by  the  local  society.  This  in- 
cludes a  number  of  subjects: 

(a)  A  list  of  desirable  laws  to  insure  the  saving  of  sight,  most  of  the  items  of  which 
are  covered  bylaws  in  force  in  Cleveland. 

MODEL  LEGISLATION  FOR  SAVING  SIGHT 

1 .  Law,  or  Regulation  of  the  Division  of  Health,  requiring  the  use  of 
a  prophylactic  in  the  eyes  of  the  new  born. 

2.  Law,  or  Regulation  of  the  Division  of  Health,  making  opthalmia 
neonatorum  a  reportable  disease,  giving  definition  of  what  may  constitute 
this  disease  so  that  no  loophole  will  be  left  for  difference  in  diagnoses. 

3 .  Law,  or  Regulation  of  the  Division  of  Health,  covering  the  training, 
examination,  licensing,  regulation  and  supervision  of  midwives. 

4.  Vital  Statistics  Law  requiring  notification  of  births  within  48  hours. 

5.  Law  prohibiting  the  use  of  the  roller  or  common  towel  in  public 
places. 

6.  Law  making  trachoma  a  reportable  disease. 

7.  Law  regulating  the  sale  and  control  of  wood  and  denatured  alcohol. 

8.  Law  making  wood  alcohol  poisoning  a  reportable  disease. 

9.  Law  making  venereal  diseases  reportable  and  providing  for  the 
quarantine  or  compulsory  treatment  of  those  capable  of  spreading  infection 
from  these  diseases. 


196  Hospital  and  Health  Survey 


10.  Law  regulating  the  projection  of  moving  pictures  and  the  lighting 
and  ventilation  of  moving  picture  theatres  and  prohibiting  the  use  of  "rainy" 
or  worn-out  films. 

11.  Law  appropriating  a  minimum  of  $250  a  year  for  each  child  requir- 
ing the  benefits  of  a  conservation  of  vision  class. 

12.  Law  providing  for  the  examination  by  an  eye  expert  of  all  inmates  of 
penal  and  charitable  institutions. 

(b)  Suggestions  for  the  better  training  of  physicians,  dentists  and  nurses  in  sight 
saving. 

(c)  An  extensive  program  for  maternal  and  child  care  from  prenatal  to  employment 
age.  This  does  not  differ  materially  from  the  recommendations  given  under  Child  Hygiene 
in  Part  III. 

(d)  Proposed  use  of  eye,  general  and  venereal  disease  clinics  for  saving  the  sight  of 
the  adult  population.  This  is  dealt  with  in  Part  X.  under  the  discussion  of  the  dispensary 
needs  of  Cleveland. 

(e)  A  model  plan  for  saving  sight  in  industry  which  gives  detailed  recommendations 
under  the  following  headings: 

1.  Lighting  conditions,  natural  and  artificial. 

2.  Protection  against  industrial  poisons  affecting  the  sight. 

3 .  Adoption  of  the  safe  methods  for  the  handling  of  acids. 

4.  Routine  examination  of  tools,  especially  of  those  likely  to  become 
"mushroomed"  or  "burred." 

5.  Routine  examination  of  machinery  and  safety  devices. 

6.  Examination  of  the  eyes  of  workers  before  entering  industrial  occu- 
pations. 

7.  Care  in  the  placement  of  one-eyed  workers. 

8.  Arrangements  for  adequate  first  aid  for  removing  foreign  substances 
from  the  eye,  and  for  treatment  of  eye  injuries,  especially  of  caustic  and  acid 
burns.  ,  ■ 

9.  Education  of  workers  in  the  use  of  safety  devices  and  methods  and 
in  preventing  accidents  to  themselves  and  others. 

The  Associated  Charities 

The  Associated  Charities  is  properly  included  among  the  health  agencies, 
since  social  reconstruction,  the  holding  together  and  supporting  of  family 
groups  by  tactful  and  timely  aid  and  well  considered  advice,  plays  as  great  a 
part  as  medical  services  in  relieving  anxiety  and  reestablishing  household 
morale. 

During  the  past  year  the  Associated  Charities,  operating  from  ten  sta- 
tions, aided  3,676  families  (including  239  homeless)  numbering  16,803  indi- 
viduals,   toward   normal   family   life.     Through    56   trained   field   workers, 


Private  Health  Agencies  197 

including  Visiting  Housekeepers  and  a  Visiting  Sewing  Teacher,  57,516 
visits  were  made  in  behalf  of  those  needing  assistance;  relief  in  the  form  of 
food,  fuel,  shelter  and  clothing  was  provided  to  1,168  families  in  their  homes; 
its  initial  Nutrition  Center  for  undernourished  children  was  conducted;  at 
the  Sewing  Center  8,640  old  garments  were  salvaged  and  11,842  new  ones 
made  for  free  distribution;  at  Wayfarers'  Lodge  15,211  meals  and  4,834 
lodgings  were  furnished  to  convalescents  and  homeless  (40  per  cent  women 
and  children);  eight  classes  in  social  work  were  conducted,  training  114 
paid  and  volunteer  workers  for  community  service.  Eighty  people  serve  in 
this  organization  and  the  annual  expenses  were  about  $250,000  in  the  past 
12  months. 

The  Welfare  Federation 

A  good  description  of  the  Welfare  Federation  will  be  found  in  the  intro- 
ductory chapter,  Part  L,  giving  the  history  of  its  development  and  its  present 
position  as  a  coordinating  agency  for  all  the  component  groups  engaged  in 
some  form  of  public  welfare.  Each  of  its  associated  organizations  has  been, 
to  a  greater  or  less  degree,  under  observation  in  the  present  study  and  to  all 
we  owe  thanks  for  their  unremitting  courtesy  and  helpfulness. 

A  special  study  was  requested  at  the  beginning  of  the  Survey  period,  to 
permit  of  recommendations  in  the  field  of  orthopedics  and  the  following 
chapter  gives  the  result  of  the  inquiries  which  were  made. 

THE   CARE  OF  CRIPPLES  IN   CLEVELAND* 

General  Considerations 

The  facts  that  strike  one  in  a  study  of  the  provision  for  cripples  in 
Cleveland  are  that  less  than  25  per  cent  of  the  960  cripples  enrolled  in  the 
regular  classes  of  the  public  schools  are  under  any  orthopedic  supervision  or 
treatment,  and  that  there  has  been  neither  recognition  nor  leadership  pro- 
vided by  the  Western  Reserve  University  Medical  School  for  this  specialty. 

Boston,  with  a  metropolitan  population  of  1,500,000,  has  forty  specialists 
in  orthopedic  surgery  with  teaching  or  hospital  affiliations.  They  are 
well  occupied  and  supported  by  the  medical  profession  and  the  public.  In 
Cleveland  and  its  vicinity  there  are  but  seven  physicians  limiting  their 
practice  to  orthopedics,  and  of  these  but  four  have  permanent  hospital 
affiliations. 

The  experiences  and  triumphs  of  orthopedic  surgery  during  the  war  have 
opened  the  eyes  of  the  laity  and  of  the  medical  profession  to  the  indefinite 
possibilities  for  human  salvage,  for  prevention  of  deformity  and  dependency, 
and  for  the  re-establishment  of  function  in  those  disabled  in  the  spinal  col- 
umn or  in  the  extremities,  such  possibilities  having  been  in  the  past  hardly 
conceived  of  outside  of  a  few  groups  of  leaders  in  the  profession. 

It  will  be  sufficient  here  to  point  out  that  the  specialty  of  orthopedic 
surgery  differs  from  most  other  specialties  in  that  it  is  a  specialty  of  prin- 

"Consultant  in  Orthopedics,  Dr.  Robert  B.  Osgood,  President  of  the  .American  Orthopedic  Asso- 
ciation. 


198  Hospital,  and  Health  Survey 

ciple  and  not  of  an  anatomical  region.  This  principle  may  be  briefly  defined 
as  a  principle  of  the  return  of  function  in  lesions  of  the  extremities  and 
spinal  column.  If  it  can  meet  its  obligations  we  believe  orthopedic  surgery 
should  surely  include  acute  as  well  as  chronic  lesions,  joint  infections,  acute 
internal  joint  derangements,  muscular  and  ligamentous  strains,  etc.,  but  the 
majority  of  cases  referred  to  it  will  comprise  the  more  or  less  chronic  lesions, 
in  which  the  return  of  wage  earning  capacity  in  the  shortest  possible  time,  is 
the  chief  desideratum.  The  burden  of  the  cripple  will  continue  to  be  its 
burden,  but  the  burden  should  be  accepted  while  the  crippling  is  acute  and 
potential  as  well  as  when  it  is  chronic  and  perhaps  permanent. 

Already  the  Industrial  Accident  Insurance  Commission  of  a  great  state 
(California)  has  become  aware  of  the  fact  that  the  time  of  recovery  of  wage 
earning  capacity,  following  certain  types  of  bone  and  joint  injuries,  varied 
very  greatly  when  the  patients  were  cared  for  by  different  physicians  whose 
general  standing  in  the  community  was  equally  good.  They  have  found  it 
a  matter  of  wisdom  and  economy  to  turn  over  these  patients  to  a  specially 
organized  group  connected  with  a  State  Medical  Institution,  which  group 
have  been  especially  devoting  their  attention  not  only  to  intelligent  surgery 
but  to  methods  of  treatment  which  produced  the  quickest  return  of  function. 
Orthopedic  surgeons  more  than  surgeons  of  any  other  specialty  have  been 
obliged  to  devote  their  attention  more  completely  to  this  class  of  cases.* 

There  are,  moreover,  in  every  community  large  numbers  of  children  and 
adults  whose  ordinary  efficiency  is  impaired  and  whose  recovery  from  any 
lesion  is  inhibited  by  the  acquired  bad  mechanical  use  of  the  body,  which 
under  proper  training  is  usually  capable  of  correction.  This  class  increases 
as  the  facts  become  known.  The  great  undergraduate  universities  are 
recognizing  this  class  and  have  taken  well  considered  steps  to  increase  the 
physical  well-being  of  their  students  by  educating  them  in  principles  of 
bodily  mechanics.  This  obligation  is  not  assumed  by  the  Western  Reserve 
University  at  Cleveland.  The  size  of  the  class  in  any  community  needing 
this  education  can  be  readily  gauged  by  the  rejections  in  the  army  on  this 
account  and  the  breakdown  under  rigid  training  of  large  numbers  of  those 
who  had  been  actually  accepted. 

Let  us  briefly  summarize  the  functions  to  be  fulfilled  in  our  opinion  by 
any  orthopedic  organization: 

1.  The  efficient  treatment,  operative,  mechanical  and  physiotherapeutic  of 
crippling  conditions  of  the  extremities  and  spinal  column,  looking  to  the 
fullest  and  quickest  return  to  wage  earning  capacity. 

2.  The  prevention  of  deformity  in  potentially  crippling  conditions  in  chil- 
dren and  adults. 

3.  The  education  of  the  community  in  bodily  mechanics. 

To  fulfill  these  functions  it  would  seem  to  be  necessary  to  arrange  for: 

1.  A  Professor  of  Orthopedic  Surgery  in  the  local  medical  school,  of  recognized 
ability  in  the  specialty  and  with  a  faculty  of  unselfish  leadership. 

•Valuable  information  as  to  the  extent  of  disabling  injuries  in  the  Cleveland  district  and  the  large 
field  for  the  functional  rehabilitation  of  in:ured  wage  earners  by  orthopedic  surgery  and  physiotherapy 
wiil  be  found  in  the  recent  report  of  the  State  Industrial  Commission. 


Private  Health  Agencies  199 


2.  Orthopedic  Departments  in  all  the  acute,  sub-acute  and  convalescent 
teaching  hospitals  organized  under  the  Division  of  Surgery,  but  with 
their  Chiefs  of  Service  holding  the  same  rank  as  the  Chiefs  of  General 
Surgery  and  other  specialties. 

3.  Facilities  for  the  administration  of  those  forms  of  physiotherapy,  which 
are  recognized  of  proved  value,  this  administration  to  be  directed  by  a 
Medical  Chief  familiar  with  the  mechanical  details  and  capable  of  carrying 
out  and  supervising  in  a  consultatory  manner  the  treatment  prescribed 
by  the  physicians  and  surgeons. 

4.  Facilities  for  the  manufacture  of  braces  and  appliances,  and  at  least  the 
simpler  forms  of  prostheses. 

Departments  of  orthopedic  surgery  in  general  hospitals  are  desirable  in 
out-patient  and  house  service. 

Whether  or  not  the  acute  fractures  other  than  the  joint  fractures  should 
be  considered  as  orthopedic  cases  should,  in  our  opinion,  depend  solely  upon 
whether  certain  general  surgeons  of  the  community  or  certain  orthopedic 
surgeons  have  had  the  larger  experience  in  the  treatment  of  these  lesions 
and  whether  they  retain  their  interest  to  continue  to  supervise  the  many 
necessary  details  of  this  treatment,  looking  to  the  fullest  and  most  rapid 
return  of  function.  At  least  we  believe  there  should  be  constant  orthopedic 
consultation  in  fracture  cases  in  relation  to  mechanical  treatment,  preven- 
tion of  deformity  and  early  return  of  function. 

Social  Service  workers  as  an  integral  part  of  the  orthopedic  department 
have  proved  to  be  of  great  value.  In  the  system  now  in  operation  at  the 
Massachusetts  General  Hospital  in  Boston  a  head  social  worker  and  several 
assistants  are  assigned  to  the  Orthopedic  Out-Patient  Clinic  and  have  an 
office  in  the  clinic.  All  cases  needing  investigation  of  their  home  conditions, 
or  help  in  obtaining  apparatus,  or  more  detailed  explanation  of  their  pro- 
posed treatment  are  referred  to  this  office  and  the  history  card  stamped 
"Social  Service."  All  cases  referred  to  the  hospital  for  operation  or  bed 
treatment  are  automatically  interviewed  by  the  Social  Service  worker  and 
the  home  situation  which  this  emergency  creates  is  ascertained.  By  means 
of  a  card  system  cases  not  reporting  back  to  the  clinic  on  the  day  set  for  their 
return  are  followed  up,  and  when  statistics  were  last  taken  a  35%  loss  was 
reduced  to  4%,  The  cases  in  the  ward  are  visited  by  the  House  and  Out- 
Patient  Social  Service  Worker  and  arrangements  for  transfer  to  their  homes 
and  immediate  after  care  are  made.  The  service  has  a  peculiar  value  to  an 
orthopedic  department. 

A  distinct  Children's  Service  in  General  Hospitals  for  acute  and  sub- 
acute cases  is  needed  unless  a  separate  children's  hospital  is  provided,  and  a 
ward  or  wards  should  be  set  apart  for  children  orthopedic  patients. 

There  are  many  adult  cases  needing  operation  and  bed  treatment  for 
chronic  lesions  of  the  bones  and  joints  and  spinal  column,  whose  stay  in  a 
hospital  for  acute  and  sub-acute  cases  need  be  only  two  or  three  weeks, 
provided  they  could  be  recumbent  one  or  two  months  longer  in  some  con- 


200  Hospital  and  Health  Survey 

valescent  or  sub-acute  hospital  which  could  be  administered  with  less  ex- 
pense than  an  acute  hospital.  The  problem  of  convalescents  has  been  shown 
to  be  an  important  one.  A  few  weeks  longer  in  recumbency  or  under  physio- 
therapeutic treatment,  perhaps  directly  following  their  surgical  treatment, 
often  saves  many  weeks  of  idleness  and  brings  about  a  much  more  permanent 
and  complete  recovery  of  wage  earning  capacity.  Beds  are  needed  for  con- 
valescent patients  in  hospitals  where  their  treatment  may  continue  to  be 
directed  by  the  same  surgeons  under  whose  care  they  were,  in  the  acute 
hospitals. 

Simple  physiotherapeutic  plants  would  prove  valuable  in  every  sub- 
acute and  convalescent  hospital.  By  this  we  mean  simple  hydrotherapy 
apparatus,  whirlpool  bath  and  douches,  electric  apparatus  for  diagnosis, 
and  the  simpler  forms  of  treatment  by  radiant  light,  baking,  galvanism  and 
Faradism  (Bristow  coil),  one  or  two  universal  exercising  machines  of  the 
pendulum  type,  and  facilities  for  massage. 

If  there  were  a  main  physiotherapy  plant  to  serve  all  hospitals  more 
elaborate  and  complete  hydrotherapeutic,  electrotherapeutic,  and  mechano- 
therapeutic  apparatus  could  be  installed  and  very  properly  simple  curative 
workshops  established.  These  workshops  might  very  well  be  made  more 
than  self-supporting.  Such  a  central  facility  for  physiotherapy  would 
benefit  many  types  of  patients  other  than  purely  orthopedic,  and  while  per- 
haps the  interest  of  orthopedic  surgeons  in  these  methods  has  been  more 
intense  than  that  of  other  medical  men,  few  of  them  in  our  experience  are 
at  present  sufficiently  well  trained  to  administer  these  measures.  Experi- 
enced medical  supervision  of  a  consultatory  character  will  be  required  if  the 
results  hoped  for  by  physicians  and  patients  are  to  be  expected.  Without 
this  dual  control  there  is  danger  that  the  treatment  may  be  futile  or  the 
service  become  a  fad  only.  Frequent  and  accurate  records  of  progress  are 
required  in  such  work,  in  order  that  results  may  be  measured.  The  interest 
of  the  patients  is  greatly  stimulated  by  such  records.  This  orthopedic  cen- 
ter could  with  much  advantage  be  incorporated  in  or  be  associated  under 
the  same  management  with  the  proposed  down-town  central  dispensary 
serving  especially  pay  industrial  accident  patients.  The  benefits  of  a 
group  of  medical  and  surgical  diagnosticians  available  for  consultation  and 
reference  at  such  a  center  would  be  of  much  importance  to  an  orthopedic 
or  physiotherapy  center  and  vice  versa. 

Brace  and  appliance  shops  operated  in  general  hospitals  are  convenient, 
but  rarely,  we  believe,  successful  from  either  a  business  point  of  view  or  from 
the  point  of  view  of  furnishing  the  highest  grade  of  apparatus  at  least  cost 
to  the  patients.  If  there  were  a  central  brace  shop  where  a  representative 
of  the  shop  might  measure  the  patients  for  apparatus  ordered  by  the  sur- 
geon, the  surgeon  being  present  when  necessary  and  practicable,  errors 
would  be  avoided  and  changes  of  apparatus  would  prove  unnecessary  which 
entail  extra  expense  to  the  shop  or  patient  and  delay  the  delivery.  In  one 
hospital  shop  before  this  method  was  adopted  it  was  estimated  that  one-half 
the  labor  of  the  shop  was  employed  in  making  unnecessary  alterations. 
The  shop  should  include  metal  work,  leather  work,  the  fitting  of  corsets  and 


Private  Health  Agencies  201 


corset  belts,  the  making  of  pylons  and  perhaps  even  the  provisional  jointed 
prostheses. 

In  general  the  problem  of  the  care  of  the  crippled  in  a  given  community 
involves  consideration  of  its  acute  hospital  and  dispensary  facilities;  of  the 
availability  of  the  services  of  men  especially  trained  in  that  branch  of  sur- 
gery known  as  orthopedic  surgery  and  of  the  teaching  opportunities  afforded 
in  this  specialty.  It  also  involves  consideration  of  the  resources  for  con- 
valescent care;  of  the  facilities  for  the  practice  of  all  such  branches  of  physio- 
therapy as  are  known  to  be  helpful  in  functional  restoration ;  of  the  resources 
for  the  provision  of  braces  and  other  special  apparatus;  and  of  the  machinery 
at  hand  for  both  medical  and  social  follow-up  work  with  such  additional 
resources  as  special  schools  for  crippled  children,  funds  for  the  provision  of 
artificial  limbs,  facilities  for  transportation  to  and  from  dispensaries,  place- 
ment agencies  for  handicapped  persons,  etc. 

In  studying  the  problem  of  the  care  of  the  crippled  in  Cleveland  the  Hos- 
pital Survey  has  endeavored  to  learn  first  the  scope  and  character  of  existing 
resources;  to  discover  thereupon  the  unsatisfied  needs,  and  finally  to  formu- 
late a  program  adequately  covering  the  entire  field  and  involving  the  least 
change  or  expense  which  is  compatible  with  thorough-going  work. 

Teaching  of  Orthopedics 

Until  this  year  the  teaching  of  orthopedic  surgery  in  the  Western  Reserve 
University  Medical  School  has  been  carried  on  as  a  subdivision  of  the  De- 
partment of  General  Surgery.  There  have  been  a  few  lectures  with  clinical 
demonstrations  and  there  has  been  a  short  course  of  clinical  instruction  in 
the  dispensary  and  in  the  wards  of  Lakeside  Hospital. 

By  recent  vote  of  the  Medical  Faculty  the  Department  of  Orthopedic 
Surgery  is  now  separate  from  that  of  General  Surgery,  and  the  professor  of 
this  department  will  have  a  service  in  the  university  hospital  under  his  own 
direction.  Every  effort  is  now  being  made  to  obtain  for  the  head  of  this 
department  an  outstanding  leader  in  the  profession.  Much  for  the  future  of 
orthopedics  in  Cleveland  depends  upon  the  personality  and  professional  at- 
tainments of  the  head  of  the  department  in  the  medical  school. 

The  dispensary  equipment  as  proposed  for  the  new  Lakeside  and  Babies' 
Hospitals  will  give  every  facility  for  teaching  not  only  diagnosis  but  the  modern 
resources  for  rehabilitation  of  orthopedic  defects  by  occupational  therapy 
and  by  the  use  of  muscle  training,  and  hydro-  and  mechano-therapeutic 
appliances,  etc.  While  it  may  continue  to  be  impracticable  to  offer  the 
undergraduate  medical  student  more  than  a  brief  introduction  to  the  principles 
and  practice  of  orthopedic  surgery,  the  facilities  available  and  the  clinical 
material  which  will  always  be  at  hand  in  a  city  of  the  size  of  Cleveland,  and 
particularly  the  type  of  patient  found  in  abundance  wherever  there  is  such  a 
range  of  industries  and  employment  of  men  and  women  among  machines,  offer 
a  tempting  opportunity  to  develop  special  courses  for  graduates  or  even  to 
the  fourth  year  student  who  wishes  to  specialize  at  once.     The    coordination 


202  Hospital  and  Health  Survey 

of  the  city's  clinical  resources  with  the  agencies  for  the  social  follow-up  and 
convalescent  care  and  schooling  of  cripples  offers  an  unusual  range  of  experi- 
ence in  study  of  the  preventive  and  family  problems  of  orthopedics. 

Hospital  Service 

At  Lakeside,  Mt.  Sinai,  St.  John's  and  St.  Alexis  Hospitals  there  are 
specialists  in  orthopedic  surgery  in  charge  of  such  patients  as  are  generally 
admitted  under  this  classification.  It  is  not  usual  in  Cleveland  to  include 
fractures  among  orthopedic  patients,  and  at  no  hospital  in  Cleveland  is  there 
organized  what  is  sometimes  spoken  of  as  a  fracture  team,  consisting  of  a  gen- 
eral surgeon,  an  orthopedic  surgeon  and  a  neurologist.  It  is  not  customary 
and  it  may  be  said  it  is  not  suitable  with  the  present  shortage  of  hospital  beds 
in  Cleveland  to  set  aside  a  definite  number  of  beds  for  the  exclusive  use  of 
orthopedic  patients.  There  are  usually  to  be  found  at  Lakeside  Hospital 
about  ten  orthopedic  patients  receiving  bed  care,  from  three  to  fifteen  being 
the  range  noted  during  the  survey.  There  are  a  few  orthopedic  patients  at 
Mt.  Sinai  Hospital,  rarely  more  than  six  to  ten,  in  wards  and  in  semi-private 
rooms.  At  St.  John's  Hospital  there  are  usually  two  or  three  and  sometimes 
as  many  as  five  orthopedic  bed  patients.  At  St.  Luke's  Hospital,  where 
orthopedic  patients  are  not  under  the  care  of  orthopedic  specialists,  there 
are  commonly  a  few  (three  to  six)  cases. 

The  service  at  St.  Alexis  Hospital  has  only  recently  been  organized  under 
a  specialist  in  orthopedics,  and  the  use  of  beds  is  irregular,  but  certain  to 
increase,  especially  among  industrial  accident  patients. 

Dispensary  Services 

Dispensary  facilities,*  more  or  less  complete,  are  offered  at  six  hospitals. 
The  physiotherapy  facilities  in  Cleveland  are  extremely  limited. 

Lakeside  has  three  orthopedic  clinics  a  week  with  an  average  attendance 
of  10  to  12.     No  physiotherapy  staff. 

Mt.  Sinai  has  an  orthopedic  clinic  open  every  day  from  9  to  10:30  and 
2:30  to  5:30.  During  11  months  of  1919,  5,818  physiotherapeutic  treatments 
were  given.  The  clinic  is  equipped  with  two  Zander  machines,  quarter  circle 
pulleys,  hanging  apparatus,  dumb  bells,  and  has  facilities  for  general  massage, 
and  four  well  trained  masseuses. 

St.  John's  has  no  dispensary,  but  treatments  are  given  every  day  to  out- 
patients at  all  hours  by  two  trained  physiotherapists.  Emphasis  is  placed 
on  hydrotherapy.  This  hospital  also  has  an  electric  light  cabinet,  steam 
cabinet  and  facilities  for  general  massage.  Patients  will  be  accepted  from 
other  hospitals  or  dispensaries  for  treatment. 

St.  Vincent's  has  no  orthopedic  staff.  Cases  discharged  from  the  wards 
are  followed  up.  There  is  an  attendant  trained  in  physiotherapy.  General 
massage  is  given  and  electrical  and  steam  cabinet  treatments  are  provided. 

•For  special  report  on  all  dispensary  services  in  Cleveland,  see  Part  X. 


Private  Health  Agencies  203 

The  Babies'  Dispensary  and  Hospital  has  an  attendant  trained  in  physio- 
therapy and  has  equipment  for  massage  and  simple  electrical  treatment. 
Clinic  open  three  days  a  week  from  9  to  11.  Children  up  to  the  age  of  14 
are  admitted.  The  average  attendance  is  12  children  a  month.  An  ortho- 
pedist visits  the  clinic  once  a  month  for  supervision. 

St.  Alexis  has  three  orthopedic  clinics  a  week.  There  are  no  facilities  for 
physiotherapy. 

Convalescent  Services 

Convalescent  care*  for  crippled  children  to  the  age  of  14  is  provided  by 
Rainbow  Hospital  up  to  75  beds.  The  Fresh  Air  Camp  receives  ambulatory 
crippled  children  to  the  same  age  to  a  capacity  of  50  beds.  The  Warrens- 
ville  Tubercular  Sanitarium  and  Children's  Cottage  give  convalescent  care 
to  crippled  children  and  adults  who  are  suffering  with  a  pulmonary  compli- 
cation. The  Warrens ville  Infirmary  is  the  last  resort  for  convalescent  care 
for  crippled  adults  and  for  children  who  are  beyond  the  age  limits  set  by  Rain- 
bow Hospital  and  the  Fresh  Air  Camp,  but  at  this  city  institution  no  ortho- 
pedic treatment  is  provided. 

Brace-maker 

Lakeside  Hospital  gives  space  in  the  basement  of  the  hospital  to  a  brace- 
maker.  The  bracemaker  gives  special  rates  to  all  hospitals  in  the  city. 
This  service  is  used  by  all  the  hospitals  and  by  the  orthopedists.  No  com- 
plaint is  made  as  to  quality  of  service  rendered,  but  the  facilities  are  entirely 
inadequate.     Often  it  is  necessary  to  wait  weeks  or  months  for  a  brace. 

Social  Service 

The  social  service  facilities  for  orthopedic  patients  as  provided  at  several 
of  the  hospitals,  Lakeside,  Mt.  Sinai  and  Rainbow,  lack  completeness,  and 
even  with  the  central  assistance  of  the  Association  for  Crippled  and  Dis- 
abled, fail  in  their  full  possibilities  both  in  doing  most  for  the  patients  and 
in  providing  for  optimum  use  of  hospital  and  dispensary  services. 

Lakeside  has  an  insufficient  social  service  staff  for  adequate  follow-up 
work.  The  children's  worker  devotes  most  of  her  time  to  the  orthopedic 
cases.  She  admits  all  the  children  during  dispensary  hours,  but  does  noth- 
ing further  in  the  children's  clinic.  She  assists  in  the  orthopedic  clinic  and 
arranges  for  hospital  admission.  She  spends  most  of  her  mornings  visiting 
in  the  homes  of  orthopedic  children.  She  arranges  convalescent  care  for 
the  orthopedic  cases  and  occasionally  for  other  children's  cases  from  the 
hospital. 

Mt.  Sinai  has  an  insufficient  social  service  staff  but  has  a  fine  spirit  of 
cooperation.  One  graduate  nurse  does  the  follow-up  work  for  orthopedic 
cases,  giving  about  one  afternoon  a  week.  Financial  investigations  are 
made  by  the  head  of  the  clinic.  If  the  patient  fails  to  attend  clinic  a  follow- 
up  visit  is  made  to  the  home  to  discover  the  reason  for  non-attendance. 

•For  special  consideration  of  the  problem  of  convalescent  care  of  all  kinds,  see  Chapter  on  Con- 
valetcents,  Part  X. 


204  Hospital  and  Health  Survey 

Rainbow  Hospital  has  endeavored  to  keep  in  touch  with  the  children  dis- 
charged from  Rainbow  as  long  as  anything  medically  or  surgically  could  be 
done  for  them.  The  Social  Service  Department  of  the  Association  for  the 
Crippled  and  Disabled  has  done  medical  and  social  follow-up  work  with  all 
persons  referred  to  its  attention. 

One-fourth  of  the  income  from  the  Benjamin  Rose  Institute  is  available 
to  provide  funds  for  the  hospital  and  dispensary  care  of  crippled  children. 

The  Association  for  the  Crippled  and  Disabled 

The  Association  for  the  Crippled  and  Disabled,  a  very  valuable  co- 
ordinating agency,  has  a  board  of  trustees  elected  to  be  representative  of  all 
groups  especially  interested  in  the  crippled  problem.  At  the  present  time 
the  board  members  include  representative  members  of  Rainbow  Hospital, 
Holy  Cross  House,  the  Hospital  Council,  Babies'  Dispensary  and  the  Public 
Schools.  The  Board  members  also  include  a  large  representation  of  what 
was  formerly  the  Sunbeam  Association  for  Cripples,  which  organization  and 
its  activities  were  merged  in  the  Association  for  the  Crippled  and  Disabled. 
The  Association  for  the  Crippled  and  Disabled  has  also  recently  asked  for 
representation  from  the  Rotary  Club,  which  is  now  interested  in  crippled 
work.  An  orthopedic  council  has  recently  been  formed  at  the  request  of  this 
association  for  the  purpose  of  providing  for  the  expression  of  opinion  and 
forming  professional  policies  for  the  Association,  by  joint  action  of  the 
specialists  in  orthopedic  surgery  in  Cleveland. 

The  Association  functions  through  the  following  committees  and  depart- 
ments : 

The  Committee  on  Orthopedic  Resources  works  to  organize  and  co- 
ordinate the  orthopedic  resources  of  the  city  to  the  end  that  all  orthopedic 
needs  may  be  adequately  met  in  the  most  efficient  manner  possible. 

The  Social  Service  Department  embraces  the  following  activities: 

The  securing  of  expert  medical  diagnosis  and  making  possible  any  treat- 
ment indicated. 

The  furnishing  of  transportation  and  accompanying  patients  to  hospitals, 
dispensaries,  etc. 

The  furnishing  and  having  repaired  braces,  special  shoes,  artificial  limbs, 
etc. 

Arranging  for  vocational  training  and  special  schooling  as  well  as  provid- 
ing recreation  and  offering  vacation  opportunities  and  arranging  for  friendly 
visitors. 

Providing  equipment  necessary  for  employment,  supplying  home  teachers 
to  home-bound  crippled  children  of  school  age  and  arranging  for  a  supply 
of  magazines,  delicacies,  toys,  etc.,  for  them. 

Providing  outings  and  festivities  for  the  children  in  the  School  for  Crip- 
pled Children. 


Private  Health  Agencies  205 

Through  its  Social  Service  Department  the  Association  aims  to  insure 
to  every  crippled  person  in  Cleveland,  whether  child  or  adult,  the  best 
physical  condition  he  is  capable  of  attaining;  the  best  education  he  is  able 
to  assimilate;  the  best  job  he  is  competent  to  undertake. 

The  Employment  Bureau  of  the  Association  is  now  organized  in  connec- 
tion with  the  United  States  Employment  Service  and  finds  suitable  employ- 
ment for  crippled  and  disabled  men.  The  department  is  experiencing  no 
difficulty  with  organized  labor,  because  in  placing  the  handicapped  there  is 
no  effort  made  to  market  their  labor  at  a  lower  price  than  that  offered  for 
similar  service  of  physically  sound  men.  Besides  this,  the  labor  unions 
realize  that  under  certain  circumstances  men  may  work  for  less  than  the 
scheduled  union  wage,  as,  for  example,  elderly  painters  are  permitted  to 
work  for  less  than  the  standard  union  wages  when  their  physical  condition 
is  such  as  to  forbid  their  working  at  the  same  pace  as  younger  men. 

The  Bureau  is  able  to  place  approximately  fifty  cases  a  month.  In  the 
nine  months  from  April  to  December,  1919,  there  were  1,327  applications 
and  527  placements.  It  was  not  learned  what  percentage  of  these  place- 
ments were  relatively  permanent. 

The  Sunbeam  Shop  offers  employment  to  crippled  and  disabled  girls 
and  women  in  various  kinds  of  needle  work,  and  gives  a  training  course  in 
sewing  to  crippled  and  disabled  girls  and  women  desiring  to  enter  this  trade. 
The  shop  has  an  average  of  10  workers. 

The  Home  Industries  Committee  provides  work  for  home-bound  crip- 
pled and  disabled  persons,  and  furnishes  both  diversion  and  income  to  those 
whose  lives  are,  of  necessity,  greatly  restricted.  It  is  instrumental  in  mar- 
keting the  articles  produced.  During  the  month  of  April,  1920,  34  people 
were  carried  by  the  committee.  Practically  all  of  the  women  do  sewing. 
The  efforts  of  the  men  cover  a  wider  range;  i.  e.,  toy-making,  book-binding, 
finishing  work  for  tailors,  etc. 

The  Committee  on  the  Welfare  of  Cripples  in  Institutions  makes  a  study 
of  the  welfare  of  cripples  in  public  institutions,  endeavors  to  improve  these 
conditions  by  the  furnishing  of  recreation  and  employment  and  by  the  pro- 
vision of  ordinary  comforts  where  these  are  lacking. 

This  committee  has  organized  a  vocational  therapy  shop  at  Warrensville 
Infirmary,  where  the  men  work  every  day.  One  full-time  instructor  and  one 
half-time  instructor  are  at  work  in  the  wards.  The  ward  work  is  an  experi- 
ment on  the  part  of  the  Association. 

The  Committee  on  Cooperation  with  the  Public  Schools  has  the  follow- 
ing objectives: 

The  appointment  of  a  Supervisor  of  Cripple  Work  in  the  Medical  Depart- 
ment of  the  Public  Schools,  the  erection  of  a  new  and  adequate  special  school 
for  crippled  children,  the  employment  by  the  school  of  home  teachers  for 
house-bound  children  of  school  age,  the  perfecting  of  the  method  of  trans- 
porting crippled  children  to  and  from  school. 


206  Hospital  and  Health  Survey 

The  Association  has  recently  appointed  a  staff  member,  skilled  in  physio- 
therapy and  muscle  training.  Through  this  worker  an  attenpt  will  be  made 
to  give  physiotherapeutic  care  in  patients'  homes  and  in  settlements,  to  crip- 
ples not  cared  for  in  other  ways  and  for  whom  no  other  provision  can  be  made. 

Educational  Facilities  for  Cripples  in  the  Cleveland  Public  Schools 

Regular  Schools:  In  June,  1919,  there  were  960  crippled  children  en- 
rolled in  the  Cleveland  regular  public  schools.  65  of  the  960  were  discharged 
from  the  Crippled  School.  48%  of  the  960  were  disabled  by  infantile  par- 
alysis,- 15%  by  congenital  deformities,  10%  by  tubercular  bone  disease, 
5%  by  amputations,  6%  by  fractures  and  5%  by  spastic  conditions.  Less 
than  25%  of  the  crippled  children  in  the  regular  schools  of  the  public  school 
system  were  under  any  orthopedic  treatment. 

Special  School:  The  Board  of  Education  at  present  is  conducting  a 
special  school  for  crippled  children  who  cannot  take  care  of  themselves  in 
the  regular  schools,  and  is  providing  them  with  transportation  to  and  from 
.their  homes. 

In  January,  1920,  there  were  120  pupils  in  the  Cripple  School.  On  the 
waiting  list  there  were  8  who  were  out  of  school,  11  who  were  in  other  schools, 
and  30  who  were  barred  from  kindergarten  and  first  grade  on  account  of 
lack  of  room.  A  very  small  number  of  crippled  children  in  the  regular 
schools  are  candidates  for  the  special  cripple  school.  Children  are  now  being 
sent  from  the  special  cripple  school  into  the  regular  classes,  who  would  benefit 
by  a  longer  attendance  in  the  special  school.  Their  premature  discharge 
seems  the  less  of  two  evils.  By  their  transfer,  room  is  made  for  others  usually 
so  handicapped  that  without  a  created  school  vacancy  they  must  remain  at 
home. 

At  the  present  time  there  is  one  worker  who  investigates  candidates  for 
the  school. 

In  the  Cripple  School  68%  of  the  children  were  disabled  by  infantile 
paralysis,  and  12%  by  tubercular  bone  disease.  The  remaining  20%  were 
disabled  by  spastic  conditions,  amputations,  progressive  muscular  paralysis, 
congenital  deformities,  osteo-myelitis,  etc.  About  95%  of  the  children  in 
the  Cripple  School  are  under  orthopedic  surgical  supervision. 

A  lot  has  been  purchased  on  the  Fresh  Air  Camp  site  and  another  special 
school  for  cripples  will  be  built  there.  This  school  will  accommodate  about 
250.  The  architect  of  the  Board  of  Education,  after  making  a  special  study 
of  schools  for  cripples  in  many  other  cities,  has  drawn  plans  incorporating 
what  appear  to  be  the  best  features  of  each.  There  remains  simply  the 
question  of  financing  the  undertaking. 

The  Board  of  Education  expects  to  make  provision  next  year  for  the 
giving  of  special  exercises  in  the  regular  schools  to  children  with  slight  ortho- 
pedic defects.  The  present  worker  will  be  used  for  this  purpose  and  one,  or 
possibly  two,  assistants  will  be  provided  for  her. 


Private  Health  Agencies  207 

Present  Needs 

Briefly,  to  state  the  unsatisfied  needs  in  the  present  situation,  the  city 
needs  to  have  orthopedic  dispensary  facilities  developed  on  the  west  side  of 
the  river. 

All  dispensaries  and  hospitals  accepting  for  care  orthopedic  cases  should 
have  at  their  command  trained  orthopedists,  and  not  trust  such  cases  to  the 
general  practitioner,  pediatrist,  or  general  surgeon. 

The  present  facilities  for  physiotherapy  are  inadequate  and  such  as 
there  are,  because  of  location,  are  wasteful  of  the  time  of  patients. 

Rainbow  Hospital,  which  has  been  and  is  one  of  the  largest  factors  in 
crippled  work  in  Cleveland,  has  been  very  much  limited  in  its  field  of  action 
by  fact  of  the  contract  affiliating  it  particularly  with  Lakeside  Hospital. 
Although  Rainbow  has  offered  to  receive  patients  from  other  hospitals  and 
dispensaries  it  is  not  strange  that  surgeons  have  been  loath  to  send  patients 
when  by  so  doing  they  have  necessarily  lost  supervision  over  them. 

Hardship  is  wrought  by  the  fact  that  there  is  no  place  at  present  for 
convalescent  care  of  crippled  children  beyond  14  years  of  age.  When  excep- 
tions have  been  made  by  institutions  whose  age  limits  have  been  set  at  14 
the  results  have  been  almost  universally  unfortunate.  It  happens,  there- 
fore, that  no  place  is  open  to  the  adolescent  crippled  child,  save  the  wards 
of  the  Warrensville  Infirmary,  and  it  goes  without  saying  that  these  wards 
are  not  the  proper  setting  for  the  life  of  any  boy  or  girl. 

The  adult  cripple  frequently  suffers  now  along  with  many  medical  cases 
because  of  the  lack  of  opportunity  for  convalescent  care.  A  general  con- 
valescent hospital  for  all  adult  cases  would,  of  course,  greatly  relieve  the 
situation.     (See  chapter  on  "Convalescent  Care,"  Part  X.) 

The  follow-up  work  with  orthopedic  cases  has  been  erratic  and  has  suf- 
fered for  lack  of  organization.  Neither  Mt.  Sinai  nor  Lakeside  has  had  a 
social  service  staff  sufficient  to  insure  the  proper  following  up  of  cases  that 
were  receiving  medical  attention  in  the  dispensaries.  There  has  been  con- 
fusion in  the  follow-up  work  done  by  Rainbow  Hospital  due  to  the  lack  of 
careful  delimitation  of  work  with  Lakeside  Hospital.  The  follow-up  work 
of  the  Association  for  the  Crippled  and  Disabled  has  been  difficult,  because 
in  attempting  to  supplement  the  work  of  the  dispensaries  there  is  the  con- 
stant danger  of  duplication. 

The  Board  of  Education  has  not  sufficiently  recognized  the  complexity 
of  the  problem  offered  by  the  crippled  school  child  and  has  never  had  a  clearly 
defined  program  of  its  functions  in  this  connection.  It  has  not  realized  the 
opportunity  as  a  preventive  agency  in  the  matter  of  orthopedic  deformities 
nor  has  it  realized  its  obligation  to  the  crippled  children  in  the  regular  schools. 

There  are  practising  in  Cleveland  a  number  of  surgeons  who  are  devoting 
practically  their  entire  time  to  the  practice  or  teaching  of  orthopedic  sur- 
gery, or  both.  General  surgeons  and  some  of  the  practitioners  of  medicine 
who  have  much  practice  among  children  take   orthopedic  patients  in  their 


208  Hospital  and  Health  Survey 

practice  and  operate  or  prescribe  or  apply  corrective  measures.  Those 
limiting  their  practice  to  orthopedic  surgery  in  Cleveland  are  in  entire  agree- 
ment as  regards  the  deficiencies  in  the  educational  facilities  of  the  Western 
Reserve  University  Medical  School  and  in  the  matter  of  hospital  and  dispen- 
sary provision  for  patients. 

Program  and  Recommendations 

The  program  which  follows  is  offered  to  the  citizens  of  Cleveland  for  their 
consideration  and  support,  with  the  conviction  that  it  represents  the  best 
thought  of  the  specialists  of  their  city  and  is  in  substantial  agreement  with 
the  accepted  ideas  of  the  leaders  in  orthopedic  surgery  among  the  profession 
elsewhere. 

St.  John's  Hospital,  because  of  its  location,  and  because  of  the  small 
beginnings  already  made  in  hydrotherapy  and  in  orthopedic  work  in  the 
wards,  might  well  develop  an  orthopedic  department  in  connection  with  its 
future  dispensary  service.  Provision  should  also  be  made  for  the  inclusion 
of  an  orthopedic  department  in  the  extension  of  the  work  at  the  City  Hos- 
pital. With  such  additions  the  orthopedic  needs  of  the  West  Side  should 
be  fairly  met. 

The  Hospital  Survey  approves  of  the  recently  organized  Advisory  Ortho- 
pedic Council  having  as  personnel  the  heads  of  the  orthopedic  departments  in 
the  various  hospitals  and  such  other  orthopedists  as  these  men  may  choose 
to  associate  with  them.  This  group  could  meet  upon  call  of  the  secretary  of 
the  Association  for  the  Crippled  and  Disabled  to  advise  upon  any  question 
of  a  professional  or  administrative  nature  submitted  by  any  one  -of  the  groups 
responsible  for  any  phase  of  the  crippled  problem. 

There  should  be  a  central  office  which  would  take  ultimate  responsibility 
for  all  medical  and  social  follow-up  work  with  orthopedic  cases.  The  exist- 
ence of  adequate  medical  and  institutional  facilities  or,  indeed,  of  adequate 
resources  of  any  nature  does  not  necessarily  signify  real  accomplishment. 
If  lapses  in  treatment  are  allowed,  if  braces  can  be  neglected,  if  home  condi- 
tions are  destructive  of  gains  previously  made,  etc.,  the  accomplishment  of 
surgery  or  medical  treatment  may  be  nullified.  The  Survey  would  recom- 
mend that  the  Association  for  the  Crippled  and  Disabled,  which  has  already 
made  considerable  headway  with  social  service  follow-up  work  with  the 
crippled  in  Cleveland,  should  take  upon  itself  the  ultimate  responsibility 
for  insuring  that  adequate  follow-up  work  is  done  in  every  individual  ortho- 
pedic case.  However  much  or  little  of  the  actual  case  work  be  done  by  the 
Association  for  the  Crippled  and  Disabled  the  responsibility  for  insuring  that 
the  work  is  adequately  done  by  some  one  and  that  records  are  properly 
kept  should  reside  with  the  Association  for  the  Crippled  and  Disabled  Social 
Service  Department. 

There  should  be  established  a  center  of  physiotherapy  which  should  have 
a  staff  of  trained  physiotherapists  and  where  equipment  for  physiotherapy 
would  be  available.  Such  a  center  should  be  under  the  direct  supervision  of 
a  group  of  people  who  would  be  interested  in  making  it  possible  to  attain  a 


Private  Health  Agencies  209 

high  standard  of  treatment.  They  would  benefit  by  the  advice  and  sugges- 
tion of  the  Orthopedic  Council.  The  services  of  the  center  should  be  avail- 
able to  all  surgeons  of  the  Orthopedic  Council.  A  careful  plan  of  cooperation 
with  the  surgeons  should  be  worked  out  so  that  all  work  done  would  be  upon 
the  prescription  and  under  the  advice  and  supervision  of  the  surgeon  in 
charge  of  the  case,  and  such  treatment  records  should  be  kept  as  might  be 
acceptable  to  and  standardized  by  the  Orthopedic  Council. 

The  Hospital  and  Health  Survey  recommends  that: 

1.  The  Orthopedic  Council,  formed  at  the  invitation  of  the  Association  for  Crippled  and 
Disabled  and  now  organized,  include  in  its  membership  a  representative  of  the  lay 
management  of  each  hospital  which  has  a  dispensary  or  bed  service  for  orthopedic 
patients  under  the  direction  of  an  orthopedic  surgeon. 

2.  The  Association  for  the  Crippled  and  Disabled  enlarge  its  activity  to  include  the 
operation  of  an  orthopedic  center  where,  in  addition  to  fulfilling  several  of  its  estab- 
lished social  and  welfare  functions,  the  Association  should  administer  a  physiothera- 
peutic service  under  the  direction  of  an  orthopedic  surgeon  or  surgeons  nominated  by 
the  Orthopedic  Council.  This  service  should  be,  so  far  as  possible,  self-supporting 
and  should  serve  the  needs  for  all  manner  of  muscle  training,  massage  and  mechanical 
treatment  of  functional  and  structural  disabilities  of  joints,  bones  and  muscles,  and 
their  nerve  control,  referred  by  hospitals,  dispensaries,  private  practitioners,  shops, 
industries  and  schools. 

3.  The  proposed  Orthopedic  Center  include  the  central  Brace  Shop  now  located  at  Lake- 
side Hospital,  and  the 

Information  Center, 
Social  Service  Center, 
Vocational  Training  Service, 
Transportation  Service, 
Home  Industries  Activities, 
Artificial  Limbs  Fund  Service 

at  present  being  operated  by  the  Association  for  Crippled  and  Disabled,  and  that  this 
center  serve  as  the  point  of  contact  and  coordination  of  all  the  institutions  dealing 
with  cripples,  in  particular  the  acute  hospitals  with  orthopedic  services,  the  convales- 
cent hospitals  for  orthopedic  patients,  the  services  for  cripples  of  school  age,  and  the 
other  social  agencies,  such  as  the  Holy  Cross  Home,  Employment  for  Handicapped,  etc. 

4.  (a)  Not  less  than  50  beds  be  provided  for  acute  orthopedic  patients  at  the  new  Lake- 

side Hospital — 30  for  children  and  20  for  adults. 

(b)  Not  less  than  60  beds  be  provided  in  the  extension  of  Mt.  Sinai  Hospital — 40  for 
children  and  20  for  adults. 

(c)  Not  less  than  50  beds  be  provided  at  the  new  St.  Luke's — 30  for  adults  and  20  for 
children,  and  that  this  service  be  put  in  charge  of  an  orthopedic  specialist. 

(d)  Twenty  beds  be  provided  at  St.  John's  Hospital — 10  for  adults  and  10  for  children, 
and  that  an  orthopedic  dispensary  be  established  at  this  hospital. 


210  Hospital  and  Health  Survey 

(e)  Sixty  beds  be  provided  at  City  Hospital — 30  for  adults  and  30  for  children,  this 
latter  to  include  beds  to  be  made  available  for  isolation  for  orthopedic  patients 
affected  with  acute  communicable  diseases  and  with  venereal  diseases  in  the  com- 
municable stage.  That  an  orthopedic  dispensary  be  established  at  this  hospital. 
That  ward  and  dispensary  service  be  put  under  the  direction  of  an  orthopedic 
specialist. 

(f)  Thirty  beds  for  adults  be  provided  at  St.  Alexis  Hospital  when  this  hospital  under- 
takes its  program  of  reconstruction  and  reorganization,  and  that  an  orthopedic 
dispensary  be  established  at  this  hospital. 

(g)  Holy  Cross  Home  increase  its  capacity  to  provide  for  orphan  cripples  of  older  age 
groups  (adolescents).  That  a  nurse  especially  trained  in  the  care  of  orthopedic 
patients  be  employed  constantly  at  this  institution. 

5.  The  admitting  and  assigning  authorities  of  all  hospitals  with  orthopedic  services 
either  for  bed  or  dispensary  patients  authorize  and  require  the  assignment  as  patients 
for  the  care  of  the  orthopedic  surgeon,  those  suffering  from  the  conditions  and  dis- 
eases listed  below: 

Foot  Strain  (Flat  Foot)  Hallux  Valgus, 

Scoliosis, 

Deformities  of  Rachitis 

Congenital  Deformities, 

Contraction  of  fascia  or  tendons  (resulting  in  deformities  of  joints), 

Affections  of  Bursae, 

Tuberculosis  of  Joints, 

Mon-articular  Disease — 

Gonorrhea, 

Syphilis, 

Infections, 
Deformities  of  Chronic  Polyarthritis, 
Chronic  Joint  Strain, 

Acute  Muscular  and  Ligamentous  Strain  Involving  Joints, 
Infantile  Paralysis  (after  acute  state), 

Requiring :     Prevention  of  Deformity, 
Muscle  Training, 
Apparatus,  etc., 
Spastic  Paralysis  (requiring  correction  of  deformity  and  muscle  training), 
Traumatic  derangement  of  Joints  (cartilage), 
Bone  Disease  of  Unknown  Origin,  such  as  Chondrodystrophy,  Osteogenesis  Im- 
perfecta, Adolescent  Rickets. 
Deformities  Following  Old  Fractures  into  Joints, 
Deformities  Following  Dislocations. 

6.  A  fracture  team  to  consist  of  a  general  surgeon,  an  orthopedic  surgeon  and  a  neurolo- 
gist be  organized  for  the  treatment  of  fractures  in  any  general  hospital  where  an  ortho- 
pedic specialist  and  neurologist  are  available  on  the  medical  staff. 


Private  Healtjh  Agencies  211 


7.  The  Department  of  Orthopedic  Surgery  in  the  Medical  School  and  at  the  University 
Hospital  group  be  included  under  the  general  group  of  surgery  but  be  allowed  full 
autonomy  in  the  development  of  the  specialty  in  the  diagnosis  and  treatment  of  all 
patients  falling  within  above  list  (see  5.)  and  that  special  facilities  be  provided  for 
intimate  coordination  of  ward  and  dispensary  services  with  the  social  service  depart- 
ment and  for  development  of  special  clinics  in  poliomyelitis,  scoliosis,  and  posture 
defects. 

8.  Rainbow  Hospital  be  enlarged  to  accommodate  300  orthopedic  or  other  patients  for 
convalescent  care;  that  the  service  at  Rainbow  Hospital  be  restricted  for  the  present 
to  the  convalescent  care  of  adolescents  and  children;  that  Rainbow  Hospital  accept 
patients  from  all  the  hospitals  in  the  city;  that  patients  in  the  communicable  stages  of 
gonorrhea  and  syphilis  and  those  with  open  pulmonary  tuberculosis  be  excluded; 
and  that  the  medical  staff  consist  of  the  heads  of  orthopedic  services  in  hospitals  pro- 
viding such  services,  and  such  other  orthopedic  specialists  as  may  be  considered  quali- 
fied by  the  Orthopedic  Council — the  resident  orthopedic  surgeon  to  be  nominated  by 
the  Orthopedic  Council.  ( While  Rainbow  Hospital  is,  as  now  organized  and  equipped, 
prepared  to  serve  only  the  needs  of  children,  it  may  well  be  that,  in  the  absence  of  any 
new  undertaking  for  convalescent  care  under  other  auspices,  the  Board  of  Managers 
of  Rainbow  Hospital  will  find  themselves  under  much  pressure  and  almost  a  moral 
obligation  to  extend  their  activities  to  provide  for  adults,  convalescent  from  general 
medical  and  surgical  conditions. 

9.  The  Fresh  Air  Camp  discontinue  its  service  for  cripples  as  soon  as  Rainbow  is  prepared 
to  accept  all  the  cases  offered  for  convalescent  care. 

10.  A  nurse  trained  in  the  care  of  orthopedic  patients  be  available  at  all  times  for  service 
at  Warrensville  Tuberculosis  Sanatorium.  (One  of  the  regular  nurses  always  on  duty 
could  be  trained  to  meet  this  requirement.) 

11.  A  visiting  orthopedic  surgeon  be  appointed  at  Warrensville  Infirmary  to  care  for 
convalescent  adults,  and  that  a  nurse  trained  to  care  for  orthopedic  patients  be  pro- 
vided at  this  institution. 

12.  When  an  orthopedic  service  is  established  at  City  Hospital  the  chief  of  this  service 
be  responsible  for  the  professional  care  of  the  orthopedic  cases  requiring  treatment  at 
Warrensville  Tuberculosis  Sanitorium  and  the  Warrensville  Infirmary. 

13.  To  the  responsibilities  already  assumed  by  the  Board  of  Education  in  the  care  of 
crippled  children  should  be  added  the  following: 

The  prevention,  as  far  as  may  be,  of  orthopedic  deformities  through  attention  to 
posture,  seating,  etc. 

The  recording  of  every  crippled  child  in  the  school  system. 

Provision  of  supervision  by  an  orthopedic  surgeon  for  every  crippled  child  of  school 
age  needing  such  attention.  The  orthopedic  surgeon  may  be  privately  employed  or 
his  services  secured  at  a  dispensary. 

Provision  that  each  child  report  at  proper  intervals  to  the  orthopedic  surgeon  in  charge 
of  his  case. 


212  Hospital  and  Health  Survey 

The  furnishing  of  transportation  to  dispensaries  when  such  transportation  is  a 
necessity. 

The  giving  of  simple  massage  and  special  physical  exercises,  not  requiring  elaborate 
equipment,  in  school  buildings,  under  the  close  supervision  of  the  orthopedist  in  charge 
of  each  child. 

The  keeping  of  such  records  of  these  treatments  as  may  be  suggested  by  the  Ortho- 
pedic Council. 

The  creation  in  the  public  schools  within  the  Department  of  Medical  Inspection 
of  a  Department  of  Orthopedic  Supervision;  that  the  supervision  be  by  a  trained 
physiotherapist  whose  qualifications  are  such  as  to  be  acceptable  to  the  Orthopedic 
Council,  that  such  other  trained  physiotherapists  be  employed  as  are  necessary  to 
carry  out  the  plan  as  outlined,  for  work  under  the  supervisor,  who  could  be  employed 
for  work  in  the  different  schools  as  needed. 

14.  The  governors  of  Rainbow  Hospital  request  all  nurses  training  schools  in  Cleveland 
hospitals  where  there  is  no  organized  training  care  of  orthopedic  patients  to  send  their 
nurses  for  a  period  of  not  less  than  two  months  each  to  Rainbow  for  special  training, 
before  or  after  graduation,  in  the  care  of  convalescent,  brace,  plaster,  paralytic  and 
chronic  tubercular  joint  cases,  etc. 

15.  The  support  of  the  Rotary  Club  be  enlisted  to  add  either  an  acute  or  convalescent 
orthopedic  service  to  existing  institutions  rather  than  attempt  to  create  a  new  ortho- 
pedic hospital.  It  is  apparent  that  the  need  for  acute  hospital  beds  for  orthopedic 
cases  would  be  much  relieved  if  there  were  adequate  facilities  for  convalescent  care, 
and  we  think  that  the  money  and  interest  of  the  Rotary  Club  would  be  more  effective 
if  brought  to  the  support  of  Rainbow  Hospital  than  if  a  new  undertaking,  with  all  the 
necessary  overhead  expense  to  be  met  by  the  community,  were  established  by  the 
Rotary  Club  independently. 

16.  Efforts  be  made  by  the  Faculty  of  the  Medical  School,  by  the  Academy  of  Medicine 
and  by  the  Orthopedic  Council  to  attract  to  Cleveland  well  trained  young  orthopedists 
and  to  provide  for  their  development  through  dispensary  and  hospital  services  in 
this  specialty. 


Additional  Private  Health  Agencies  Proposed 

There  are,  in  spite  of  the  generous  array  of  private  agencies  above  listed, 
several  activities  which  are  still  needed  to  give  a  completely  rounded  service 
to  the  community  in  the  field  of  preventive  medicine  applied  through  social 
organization. 

Cleveland  has  no  organization  in  the  following  fields  of  preventive  and 
social  medicine: 

The  Prevention  and  Relief  of  Heart  Disease. 
The  Prevention  and  Cure  of  Cancer. 
The  Prevention  and  Treatment  of  Mental  Disease. 
The  Prevention  and  Control  of  Venereal  Diseases. 


Private  Health  Agencies  213 


Cleveland  further  lacks  a  central  representative  popular  Public  Health 
Association,  to  which  reference  is  made  in  the  introduction  to  Part  I. 

THE  PREVENTION  AND  RELIEF  OF  HEART  DISEASE 

Through  the  courtesy  of  the  Association  for  the  Prevention  and  Relief 
of  Heart  Disease  of  New  York  the  following  text  has  been  prepared.  It 
represents  the  opinions  of  a  group  of  physicians  and  others  interested  in  these 
objects.  The  arguments  and  the  projects  proposed  have  been  in  large 
measure  applied  to  conditions  as  they  exist  in  New  York  City,  and  are  equally 
applicable  to  Cleveland. 

Reference  to  the  list  of  the  chief  causes  of  death  in  Ohio  will  disclose 
the  fact  that  deaths  from  heart  disease  are  more  numerous  than  those  from 
any  other  cause,  pneumonia  and  tuberculosis  following  heart  disease 
(in  that  order),  with  small  differences.  Deaths  in  Ohio  per  thousand 
population  in  1917,  as  reported  by  the  Bureau  of  Census,  were:  heart 
disease,  1.66;  pneumonia,  1.48;  tuberculosis,  1.42.  The  figures  for 
these  diseases  for  the  city  of  Cleveland  are  not  sufficiently  reliable  to  be 
used,  for  the  reason  that  there  is  no  established  policy  or  standard  practice 
followed  by  the  employe  of  the  Division  of  Health  concerned  with  the  classi- 
fication of  deaths  according  to  the  International  List  which  is  used  by 
statisticians  throughout  the  country.  The  report  from  the  Division  of 
Health  that  there  were  855  deaths  in  the  city  of  Cleveland  attributed  to  heart 
disease,  in  1919,  represents  considerable  margin  of  error,  but  indicates  the 
size  of  the  problem  with  which  preventive  medicine  is  faced.  At  present, 
there  are  no  facilities  especially  provided  for  the  diagnosis,  treatment,  pre- 
vention or  study  of  the  problem  of  heart  disease,  with  the  single  exception 
of  the  one  electrocardiographic  station  provided  for  clinical  use  at  the  City 
Hospital.  If  heart  disease  can  be,  to  any  degree,  prevented,  and  there  is 
good  evidence  to  believe  that  this  is  the  case,  it  is  time  that  the  facilities  and 
devices  which  are  used  elsewhere  should  be  put  into  operation  in  Cleveland. 

But  it  is  not  in  the  actual  loss  of  life  that  we  see  the  greatest  drain  upon 
the  community;  it  is  in  the  mass  of  children  and  elders  who  lead  handi- 
capped, stunted,  painful  lives  because  of  their  chronic  disease  of  the  heart. 
Until  recently,  there  has  been  but  scant  attention  paid  to  prevention  of 
heart  disease,  but  now,  thanks  to  active  organization  among  physicians 
to  accomplish  sane  measures  of  control  and  abatement  of  heart  disease,  the 
outlines  of  the  problem,  the  objects  aimed  at  through  the  prevention  and 
relief,  the  agencies  which  can  be  availed  of,  the  methods  in  use  and  found 
reliable  in  attacking  this  great  drain  upon  the  public's  health,  can  be  given 
with  some  precision.  Through  the  cooperation  of  the  Association  for  the 
Prevention  and  Relief  of  Heart  Disease,  the  following  program  has  been 
prepared  and  is  proposed  for  Cleveland,  following  the  experience  and  accom- 
plishments along  these  lines  in  New  York  City  since  1916. 

The  Amount  of  Heart  Disease  in  Cleveland 

One  of  every  15  deaths  in  Cleveland  last  year  was  reported  as  due  to 
leart  disease. 


214  Hospital  and  Health  Survey 

Two  per  cent  of  the  persons  examined  by  insurance  companies  are  re- 
jected because  of  serious  heart  defects. 

Two  -per  cent  of  industrial  workers  are  found  on  careful  examination  to 
be  the  subjects  of  definite  heart  disease. 

Two  per  cent  of  the  men  coming  before  the  draft  boards,  and  to  the 
camps,  were  rejected  by  army  medical  examiners  on  account  of  heart 
defects. 

One  and  one-half  to  two  per  cent  of  the  children  examined  in  the  schools 
show  serious  heart  defects. 

From  the  above  facts  we  may  conservatively  estimate  that  two  per 
cent  of  the  population,  or  in  the  United  States  over  2,000,000  persons,  and 
in  Cleveland  16,000  persons,  suffer  from  serious  Heart  Disease. 

The  objects  to  be  attained  in  prevention  and  relief  of  heart  disease  are: 

1.  Removal  of  the  causes  of  heart  disease. 

2.  Early  detection  of  potential  cases  of  heart  disease. 

3.  Early  detection  of  those  having  organic  disease  of  the  heart. 

4.  Suitable  care  of  the  above,  including  convalescent  care,  education,  and 
selection  of  suitable  occupations  for  those  handicapped  by  heart  disease. 

5.  Institutional  care  for  those  hopelessly  incapacitated  by  heart  disease  for 
self-support. 

6.  Economic  saving  to  the  community. 

7.  Humanitarian  prevention  of  suffering  and  incapacity. 

Agencies  Needed 

To  attain  these  objectives  it  would  be  of  advantage  to  enlist  the  interest 
of  those  who  should  see  and  appreciate  the  need,  preferably  by  organizing 
a  voluntary  committee.  Such  a  committee  devoted  to  the  problem  and  willing 
to  take  the  initiative  in  this  field  might  well  have  representatives  of  the 
Academy  of  Medicine,  the  Division  of  Health,  the  Board  of  Education,  the 
Hospital  Council,  the  Visiting  Nurse  Association,  the  social  service  workers, 
employers  in  various  trades  and  interested  citizens,  both  men  and  women. 

The  function  of  such  a  community  committee  would  be  to  develop  in- 
terest in  the  preventive  side  of  heart  disease,  to  coordinate  existing  facilities 
for  prevention  and  relief,  to  develop  new  ones  where  necessary,  and  to  act  as 
an  educational  force.  Sub-committees  on  prevention,  on  relief  and  on  educa- 
tional publicity,  would  be  found  necessary. 

The  agencies  needed  to  provide  adequate  means  for  prevention,  diagnosis, 
treatment,  etc.,  are — 

Clinical  Laboratories,  Serological,  Chemical,  X-Ray,  such  as  are  found  in 
a  number  of  the  hospitals  of  Cleveland. 

Electrocardiographic  stations,  such  as  are  found  only  at  the  City  Hospital 
at  present  in  Cleveland. 


Private  Health  Agencies  215 

Consultations  in  specialties  at  the  central  dispensary  as  suggested  in  the 
chapter   on  dispensaries. 

Follow-up   system    through   visiting  nurse  and  social  worker  services. 

Special  Cardiac  Clinics.  (New  York  has  37  such  in  operation  in  17  hospitals,  situ- 
ated so  as  to  be  of  easy  access  to  different  portions  of  the  community,  with  sessions  which 
do  not  conflict  with  school  hours,  and  in  the  evening  for  workers.)  The  professional 
and  associated  institutional  facilities  which  are  to  be  provided  through  these  special 
clinics  are: 

(a)  Medical  supervision  and  instruction  of  patients,  instruction  of  parents, 
and  instruction  of  school  teachers. 

(b)  Special  cardiac  social  service  (social  service  workers  are  employed  in 
31  classes  in  New  York  City),  which  will  provide  assistance  in  class, 
education  of  patients  and  parents,  study  of  home  conditions,  study  of 
school  conditions,  study  of  employment  conditions. 

It  is  desirable  to  arrange  for  close  affiliation  with  the  nose,  throat 
and  dental  departments  of  the  clinic,  and  to  arrange  for  admission  and 
investigation  of  patients  by  hospitals  and  for  convalescent  or  chronic  care 
where  necessary. 

Convalescent  homes  for  cardiac  patients  (similar  in  service  to  the  pre- 
ventoria  and  sanatoria  for  tuberculosis)  are  needed  for  potential  cardiacs 
and  for  those  with  organic  heart  disease  in  whom  improvement  is  to  be 
expected,  with  facilities  for  fifty  or  sixty  beds  (350  beds  available  in  New 
York),  where  medical  supervision,  educational,  (mental  and  vocational) 
exercise  and  recreational  facilities  will  be  provided.  This  is  a  function  which 
Rainbow  Hospital  could  well  perform. 

Homes  for  the  incurable  cases  of  heart  disease,  such  as  the  Warrensville 
Infirmary  will  be  when  it  is  adequately  developed  and  staffed,  are  a  necessity 
to  avoid  the  present  neglect  of  the  permanent  cardiac  invalid  for  whom 
there  is  now  in  Cleveland  no  accommodation. 

An  occupational  bureau  which  might  be  established  in  connection  with 
the  employment  bureau  at  the  City  Hall,  or  as  an  addition  to  the  employ- 
ment function  of  the  Association  for  the  Crippled  and  Disabled,  would 
provide  supervision  of  and  aid  in  vocational  education  in  selected  cases 
(each  of  the  cardiac  clinics  in  New  York  has  such  a  service),  would  provide 
for  selection  of  suitable  occupations  for  cardiacs  referred  by  hospitals,  special 
clinics,  convalescent  homes  and  private  physicians,  and  would  provide  means 
for  maintaining  close  cooperation  with  employers. 

Prevention 

In  its  broadest  aspect  the  prevention  of  heart  disease  presents  distinctly 
medical,  social  and  economic  problems. 

From  a  medical  standpoint  we  have  to  consider:  first,  the  prevention  of 
disease  in  healthy  hearts,  and  second,  the  prevention  of  disease  in  hearts 
which  have  already  been  damaged. 


216  Hospital  and  Health  Survey 

The  causes  of  primary  injury  to  the  heart  muscle  may  be  grouped  under 
those  arising  from  infectious  diseases,  those  resulting  from  intoxications,  and 
those  following  improper  modes  of  life.  The  infectious  diseases  most  fre- 
quently affecting  the  heart  are  rheumatism  and  syphilis.  The  destructive 
effects  of  syphilis  are  found  most  frequently  in  people  in  early  adult  or 
later  life,  and  this  group  involves  the  consideration  of  the  whole  problem 
of  social  hygiene,  as  described  in  the  chapter  devoted  to  that  subject.  (See 
PartV.) 

The  prevention  of  heart  disease  in  young  people  is  of  the  greatest  impor- 
tance, because  of  their  age  and  the  cost  of  their  care  to  the  community. 

The  chief  cause  of  heart  disease  in  early  life  is  acute  rheumatism. 
Although  we  do  not  know  definitely  the  causes  of  acute  rhuematism,  enough 
work  has  been  done  to  make  us  quite  certain  that  we  are  dealing  with  a 
germ  disease,  an  infection  which  probably  enters  through  diseased  tonsils, 
adenoids  or  decayed  teeth. 

Therefore,  we  consider  it  a  most  important  duty  of  parents  to  have  the 
mouths  and  throats  of  their  children  examined  once  yearly  by  a  physician. 
The  removal  of  diseased  tonsils  and  adenoids,  and  the  proper  care  of  the 
teeth,  are  the  most  effective  preventive  measures  against  rheumatism  at 
present  known  to  us.  Neglect  to  provide  the  diet  which  will  permit  of  unin- 
terrupted and  steady  development  in  weight  and  height  in  proportion  to 
age,  may  also  be  considered  a  major  cause  of  cardiac  disease  in  childhood, 
owing  to  the  lowered  bodily  resistance  to  infection  and  diminished  capacity 
for  recuperation  from  infection. 

Statistics  of  3,134  cases  of  acute  and  sub-acute  rheumatism,  gathered 
from  the  records  of  four  New  York  City  Hospitals,  show  that  the  greatest 
number  of  cases  occur  during  February,  March,  April  and  May. 

That  people  become  "run  down"  or  "below  par"  physically  during  the 
late  winter  and  early  spring  months,  is  a  fact  based  upon  common  experi- 
ence. We  do  not  know  that  this  physical  condition  makes  people  more 
susceptible  to  rheumatic  infection,  but  because  of  the  greater  frequency  of 
rheumatism  at  this  time  of  the  year,  it  would  seem  wise  to  promote  in  every- 
way possible  the  maintenance  of  good  health  during  the  winter  months. 
The  value  of  out-of-door  exercise  and  sufficient  sleep  in  well-ventilated  rooms, 
as  means  to  this  end,  cannot  be  overestimated. 

People  who  have  had  one  attack  of  rheumatism  are  especially  liable  to 
other  attacks,  and  therefore  it  is  of  the  utmost  importance  that  they  observe 
the  preventive  measures,  outlined  above,  in  reference  to  the  tonsils,  the  care 
of  teeth  and  keeping  in  good  physical  condition. 

A  person  suffering  from  an  acute  attack  of  rheumatism  should  be  placed 
under  medical  care  at  once,  and  should  be  kept  in  bed  for  some  days  after  the 
temperature  is  normal,  even  though  no  signs  of  heart  disease  can  be  found.  The 
necessity  for  a  prolonged  rest  in  bed  is  based  upon  the  knowledge  that  an 
acute  inflammatory  process,  which  we  are  unable  to  detect,  may  exist  in 
the  heart  and  subsequently  develop  into  severe  heart  disease. 


Private  Health  Agencies  217 

Adults  leading  sedentary  lives,  whose  activities  are  chiefly  mental,  who 
get  but  little  out-of-door  exercise,  who  eat  too  much  and  sleep  too  little, 
frequently  suffer  from  circulatory  changes.  The  exact  effect  on  the  heart 
of  poisons  derived  from  this  mode  of  life,  as  well  as  from  the  habitual  use 
of  alcohol,  tobacco,  tea  and  coffee  in  intemperate  amounts  cannot  be  defi- 
nitely and  precisely  stated,  but  it  is  certainly  the  part  of  wisdom  to  change 
one's  mode  of  life,  if  it  is  of  the  type  described,  and  equally  advisable  to 
restrict  the  use  of  these  poisons. 

The  social  problems  of  the  prevention  of  heart  disease  require  the  fullest 
cooperation  of  the  family,  school  authorities,  and  employers  in  caring  for 
those  whose  heart's  efficiency  has  been  impaired  by  disease. 

The  economic  problem  involved  in  the  prevention  of  heart  disease  is  of 
increasing  importance  because  in  childhood  this  disease  may  cripple  pros- 
pective wage-earners,  while  in  adult  life,  the  earning  capacity  of  the  patient 
may  be  permanently  limited  or  even  destroyed,  and  he  and  his  dependents 
become  a  charge  on  the  community.  Statistics  show  that  the  number  of 
people  incapacitated  by  heart  disease  is  already  large  and  rapidly  increasing, 
but  the  preventive  measures  outlined,  if  widely  known  and  applied,  would 
reduce  the  number  to  be  cared  for  by  the  state  and  therefore,  diminish  the 
drain  on  the  public  treasury. 

Prevention  may  be  summarized  to  include — 

Control   of  infectious   diseases,   particularly  rheumatism  and  syphilis. 

Care  of  teeth,  tonsils  and  adenoids. 

Lengthening  of  the  period  of  hospital  stay  and  convalescent  care  after 
acute  infections,  particularly  after  rheumatism  and  tonsillitis.  Hospitals  in 
Cleveland  are  not  doing  their  part  and  cannot  until  the  shortage  of  beds 
is  relieved. 

Supervision  of  home  after-care,  preferably  from  a  special  cardiac  class 
in  a  dispensary. 

More  regard  for  "growing  pains"  in  children,  commonly  found  to  be 
of  infectious  or  inflammatory  origin,  and  their  importance  often  overlooked. 

Supervision  of  nutritional  defects. 

Avoidance  of  mid-age  over-exertion,  habits,  intoxications,  etc. 

Prevention  of  decompensation  may  well  come  under  this  heading.  It  is 
really  the  prevention  of  serious  heart  breakdown  and  is  important.  Pre- 
vention of  heart  overstrain  in  those  with  a  recognized  heart  defect  is  an  im- 
portant service  of  special  cardiac  clinic  classes  for  adults. 

Detection  of  patients  with  early  or  unrecognized  cardiac  disease  is  the 
first  step  of  proper  preventive  management.  Physical  examination  of  all 
children  admitted  to  schools,  public  and  private,  is  advised.  Re-examina- 
tions should  be  made  once  a  year  where  practicable,  and  always  after  an 
acute  illness. 


218  Hospital  and  Health  Survey 

Educational  publicity  is  required  to — 

Encourage  the  use  of  physical  examinations  once  a  year  by  all  employes 
in  industry,  in  civil  service,  and  for  all  children  particularly.  (Physical  exam- 
ination should  be  made  with  clothing  removed,  and  should  include  a  search 
for  foci  of  infection,  such  as  defective  teeth,  diseased  tonsils,  etc.) 

Encourage  life  insurance  companies  to  refer  applicants  rejected  for 
cardiac  abnormalities  to  their  family  physicians  or  to  cardiac  clinics  for 
further  observation  and  advice. 

Force  upon  public  attention  the  essentially  preventable  aspects  of 
heart  disease. 

Disposition  of  patients  discovered. 

Every  child  having  rheumatism,  defective  teeth,  tonsils,  growing  pains, 
and  signs  or  symptoms  which  suggest  or  definitely  indicate  heart  disease, 
should  be  referred  to  the  family  physician,  or  if  not  available,  to  a  special 
cardiac  clinic.  This  applies  as  well  to  the  great  majority  of  adult  wage- 
earners. 

The  schools  might  well  cooperate  through  regulations  promulgated  by 
the  Board  of  Education  directing  teachers — - 

1 .  To  refer  to  physicians  for  examination  pupils  showing  symptoms  suggestive 
of  cardiac  disease. 

2.  To  issue  passes  to  permit  pupils  with  heart  disease  to  use  special  entrances 
and  exits. 

3.  To  permit  these  children  to  enter  or  leave  school  directly  before  or  after 
the  regular  time  schedule  for  normal  children. 

4.  To  excuse  cardiacs  from  physical  training,  fire  drills,  etc.,  where  the 
physician  in  charge  thinks  this  necessary. 

5.  To  lengthen  the  lunch  hour  for  these  children  in  order  to  avoid  hurry 
and  haste  in  eating. 

6.  To  revise  the  ordinary  school  regime  upon  the  receipt  of  a  report  from 
the  home  physician  that  there  must  be  an  exception  made  for  the  sake 
of  the  child's  health. 

Social  Service  workers  will  need  to  give  unusually  painstaking  follow- 
up  to — 

1.  Cardiac  patients  discharged  from  hospitals. 

2.  Cardiac  patients  attending  Cardiac  Clinics,  thus  providing  instruction 
and  advice  for  parents,  teachers,  patients  and  employers,  as  well  as 
investigation  of  conditions  of  homes,  school  and  work. 

When  cardiac  classes  or  special  clinics  are  developed,  it  will  be  advisable 
to  assign  districts  to  clinics  as  is  found  practicable  in  the  tuberculosis,  pre- 
natal and  child-welfare  services. 


Private  Health  Agencies  219 

Records  will  be  needed  in  hospitals  and  clinics,  and  they  should  include 
follow-up  notes  from  home  visits  and  notes  on  convalescent  care,  whether 
in  institutions  or  at  home.  If  there  is  a  central  record  office,  such  as  is 
proposed  for  orthopedic  patients,  a  brief  duplicate  record  should  be  filed 
there.  Transfer  cards  should  be  provided  for  use  of  patients  between  hos- 
pitals, clinics  and  convalescent  homes. 

Uniform  classification  of  patients  with  heart  defects  for  clinics,  at  least, 
is  very  desirable,  viz. : 

Class  I.  Patients  with  organic  heart  disease  who  have  never  had  symptoms 
of  cardiac  insufficiency  under  ordinary  conditions  of  activity. 

Class  II.  Patients  with  organic  heart  disease  who  have  had  such  symptoms 
previously,  but  who  do  not  have  them  at  present  under  ordinary 
conditions  of  activity. 

Class  III.  Patients  with  organic  heart  disease  who  at  the  time  of  observation 
have  symptoms  of  cardiac  insufficiency  following  ordinary 
exertion. 

Class  IV.  Patients  with  possible  heart  disease.  Patients  who  have  abnormal 
physical  signs  in  the  heart,  but  in  whom  the  general  picture  and 
the  character  of  the  physical  signs  lead  us  to  believe  that  they  do 
not  originate  from  cardiac  disease. 

Class  V.  Patients  with  potential  heart  disease.  Patients  who  do  not  have 
any  suggestion  of  cardiac  disease,  but  who  are  suffering  from  an 
infectious  condition  which  may  be  accompanied  by  such  disease; 
or  who  have  suffered  from  such  diseases  as  rheumatic  fever,  ton- 
silitis,  chorea,  syphilis,  etc. 

Cooperation  and  frequent  communications  between  school  teachers,  pri- 
vate physicians,  social  workers,  cardiac  clinics,  and  employers  who  have 
joint  supervision  over  a  particular  cardiac.  This  should  be  provided  for 
through  the  medium  of  the  special  committee  already  suggested. 

RECOMMENDA  TIONS 

It  is  recommended  that — 

(a)  The  teaching  of  medicine  and  pediatrics  at  the  Western  Reserve  Univer- 
sity Medical  School  include  the  principles  of  prevention  of  heart  disease. 

(b)  Special  classes  for  the  diagnosis  and  management  of  heart  disease  be 
organized  at  least  at  City  Hospital  Dispensary,  Lakeside  Dispensary, 
Mount  Sinai  Dispensary,  and  at  the  Central  Downtown  Dispensary, 
as  proposed. 

(c)  Rainbow  Hospital  provide  for  convalescent  cardiac  patients  from  the 
children's  services  of  the  Cleveland  hospitals. 

(d)  Warrensville  Infirmary  provide  the  necessary  medical,  nursing,  occupa- 
tional and  recreational  services  for  the  proper  care  of  permanently 
incapacitated  cardiac  adults. 


220  Hospital  and  Health  Survey 


(e)  The  general  hospitals  of  Cleveland  do  not  discharge  patients  suffering 
from  cardiac  defect  without  arranging  either  for  adequate  convalescent 
care  or  for  dispensary  and  home  supervision. 

(f)  Physicians  having  children  in  their  care  examine  each  year  the  condition 
of  the  tonsils,  adenoids  and  teeth  of  such  patients,  with  a  view  of  de- 
tecting foci  of  infection,  by  the  removal  of  which  cardiac  disease  may 
in  some  measure  be  reduced. 

(g)  The  Board  of  Education  provide  for  special  medical  supervision  and 
administrative  concessions  for  cardiac  children. 

(h)  A  committee  be  formed  for  the  purpose  of  studying  the  resources  for 
prevention  and  relief  of  heart  disease  and  for  developing  knowledge  of 
and  interest  in  the  use  of  all  means,  including  education,  which  may  be 
relied  upon  to  prevent  the  development  of  heart  disease  or  postpone 
its  disabling  results. 

Publicity 

^■Suitable  material  for  distribution  to  teachers,  nurses,  and  friends  or 
families  of  patients  will  be  found  among  the  publications  of  the  Association 
for  the  Prevention  and  Relief  of  Heart  Disease,  in  New  York  (327  East 
57th  Street). 

Bibliography 

For  those  especially  interested  in  this,  the  most  recent  field  of  organized 
preventive  medicine,  the  following  references  will  be  found  to  contain  the 
best  information: 

Reports  of  the  Massachusetts  General  Hospital  Social  Service  Department, 
Boston.     1911,  1918. 

Reports  of  the  Children's  Heart  Hospital  of  Boston,  Mass.  Annual  since 
1912. 

The  Trade  School  for  Cardiac  Convalescents  Reports.   1913-1914,  1914-1916. 
Reports  of  the  Bellevue  Hospital  Social  Service  Department,  New  York, 
N.  Y.     1914. 

Reports  of  the  Peter  Bent  Brigham  Hospital,  Boston,  Mass.     1915,  1919. 
Reports  of  the  Burke  Foundation,  White  Plains,  New  York.     1915,  1916, 
1917-1918. 

"Heart  Disease  and  Its  Industrial  Relations."     Warren  Coleman,  M.  D., 

American  Journal  of  Public  Health,  1915,  VI,  No.  5,  452. 

"The  Prevention  and  Relief  of  Heart  Disease."  Weekly  Bulletin  of  the 
Department  of  Health  of  the  City  of  New  York,  1916,  V,  No.  37. 

"Heart  Disease  in  Infancy  and  Childhood."  A.  L.  Goodman,  M.  D., 
Archives  of  Pediatrics,  1916,  XXXIII,  No.  12. 


Private  Health  Agencies  221 


"Suggestions  for  Municipal  Control  of  Carditis."  Thomas  B.  Hegeman, 
M.  D.,  Monthly  Bulletin  of  the  Department  of  Health  of  the  City  of 
New  York,  1917,  VII,  No.  2. 

"Recent  Statistics  of  Heart  Disease  with  Special  Reference  to  its  Increased 
Incidence."  Frederick  L.  Hoffman,  Journal  American  Medical  Asso- 
ciation, 1920,  LXXIV,  No.  20,  1364. 

"The  Organized  Care  of  Cardiac  Children."  William  P.  St.  Lawrence,  M.  D. 
Hospital  Social  Service  Quarterly,  1920,  11,  151. 

"Heart  Disease  as  a  Public  Health  Problem."  Lewis  A.  Conner,  M.  D. 
Journal  American  Medical  Association,  1920,  Vol.  74,  No.  23,  page  1567. 

"Effect  of  Tonsillectomy  upon  the  Recurrence  of  Acute  Rheumatic  Fever 
and  Chorea."  William  P.  St.  Lawrence,  M.  D.  (Read  before  the 
American  Medical  Association  at  New  Orleans,  April  30,  1920 — to  be 
published). 

THE  PREVENTION  AND  CURE  OF  CANCER 

If  it  is  true,  as  it  seems  to  be,  that  one  in  ten  of  the  deaths  of  persons 
beyond  the  age  of  forty  is  due  to  cancer,  and  if  the  apparently  verified  in- 
crease in  the  death  rate  from  cancer  amounts  to  as  much  as  2.5%  per  annum, 
there  is  good  reason  for  both  public  and  private  health  agencies  to  start  upon 
their  studies  and  their  education  of  others,  so  that  at  least  the  resources  for 
early  accurate  diagnosis  and  cure  may  be  put  at  the  disposal  of  all  who  need  it. 

The  American  Society  for  the  Control  of  Cancer  which  has  led  the  coun- 
try in  this  subject  has  been  instrumental  in  organizing  state  and  local  socie- 
ties with  the  same  purpose.  No  such  society  independently  or  as  a  branch 
of  the  national  society  has  been  formed  in  Cleveland,  although  during  the 
spring  of  1920  a  number  of  Cleveland's  public  spirited  surgeons  devoted  them- 
selves for  the  better  part  of  a  week  to  lecturing  before  lay  audiences  on  the 
subject  of  early  diagnosis,  cure  and  prevention  of  cancer. 

The  National  Society  has  contributed  to  the  Survey  by  preparing  a  pro- 
gram suitable  for  adoption  by  Cleveland.  Such  an  undertaking  will  need 
the  support  of  the  Division  of  Health,  and  especially  of  any  publicity  or  edu- 
cational service  the  city  can  supply,  and  of  private  agencies,  particularly  of 
any  special  society  which  this  statement  of  the  case  may  tempt  into  existence. 

Some  of  the  activities  proposed  have  been  adopted  by  many  health 
departments.  In  no  place  have  all  the  possibilities  of  an  organized  attack 
upon  public  and  private  indifference  been  employed. 

Suggested  activities  of  a  local  Cancer  Prevention  Society  are  as  follows: 
Program  of  Activities 

As  the  purpose  of  the  National  Society  as  well  as  the  State  and  Local  Committee  is 
to  bring  essential  cancer  control  facts  to  as  nearly  as  possible  100%  of  the  adult  popula- 
tion, this  subject  of  activities  should  logically  be  considered  in  connection  with  the  appoint- 
ment of  certain  sub-committees. 


222  Hospital  and  Health  Survey 


(If  the  committee  as  a  whole  prefers  to  carry  on  the  various  phases  of 
the  program  instead  of  appointing  sub-committees,  it  would  doubtless  tend 
to  greater  efficiency  in  most  cases  if  the  main  activities  were  apportioned 
among  the  committee  members.  In  this  way  individual  members  should 
be  made  responsible  for  the  prosecution  of  definite  parts  of  the  program.) 

/.  Activities  of  a  sub-committee  for  work  with  professional  or  quasi-professional 
groups. 

(a)  Division  of  Health. 

First  ascertain  through  the  central  office  what,  if  anything,  the  Division 
has  done. 

Assist  in  securing  the  Division's  cooperation  in  printing  and  distribut- 
ing pamphlets  suggested  by  the  society. 

Encourage  the  Division  to  provide  free  examination  of  specimens  of 
suspected  cancerous  tissue  for  diagnostic  purposes. 

If  a  regular  health  bulletin  is  issued  persuade  the  editor  to  devote  cer- 
tain numbers  or  parts  of  numbers  to  cancer  control. 

The  Division  should  be  encouraged  and  assisted  in  the  preparation  of 
popular  articles  on  cancer  for  newspapers. 

If  the  Division  has  a  health  exhibit  it  should  devote  a  portion  of  it  to 
material  for  education  regarding  cancer. 

Where  health  centers  are  established  they  should  be  provided  with 
exhibits,  placards  and  literature  for  general  public  distribution. 

The  Division  should  be  urged  to  prepare  circulars  on  danger  signals  of 
cancer  for  distribution  to  all  midwives. 

(b)  Medical  Associations,  Academies  and  Societies. 

As  above,  find  out  first  of  all  by  writing  to  the  National  Society  Office 
what  has  been  done  by  these  organizations. 

Assist  the  Central  Office  in  securing  the  appointment  of  a  permanent 
Cancer  Committee  in  the  Academy  of  Medicine. 

Encourage  all  such  organizations  to  cooperate  with  the  society  and  other 
organized  groups  in  educating  both  the  medical  profession  and  the  public. 

Endeavor  to  have  each  medical  organization  devote  at  least  one  meeting 
each  year  for  its  own  members  to  a  discussion  of  cancer,  and  hold  at  least  one 
public  meeting  on  the  same  subject  each  year  (perhaps  in  cooperation  with 
other  groups  or  with  the  Division  of  Health.) 

Present  to  all  organized  medical  groups  their  responsibility  for  the 
education  of  the  medical  profession  and  attempt  to  have  them  publish, 
either  alone  or  in  cooperation  with  the  Health  Division,  the  society's  hand- 
book for  this  purpose. 


Private  Health  Agencies 


Encourage  the  publication  of  good  articles  on  cancer  in  state  and  local 
medical  journals. 

(c)  Hospitals  and  Dispensaries. 

Prepare  posters  and  placards  on  cancer  for  bulletin  board  display. 

Encourage  the  distribution  of  appropriate  literature  on  the  subject  to 
patients. 

(d)  Nursing  Organizations  and  Schools. 

Every  training  school  for  nurses  should  be  urged,  through  the  appropriate 
surgeon  of  the  hospital,  to  include  cancer  control  in  the  lecture  course. 

All  such  schools  should  be  supplied  with  the  special  literature  prepared 
for  nurses  by  the  society. 

Efforts  should  be  made  to  provide  speakers  for  meetings  of  state  nurses' 
associations  and  before  local  nurses'  organizations  and  clubs. 

All  public  health  nurses  should  be  provided  with  the  society's  special 
nurses'  literature. 

A  special  effort  should  be  made  to  acquaint  all  industrial  nurses  with  the 
facts  necessary  for  their  use  in  advising  employes  on  the  subject  of  cancer. 

(e)  Medical  Schools  and  Colleges. 

A  special  effort  should  be  made  through  the  dean  or  head  of  the  Depart- 
ment of  Pathology  to  give  due  attention  to  instruction  of  students  in  the 
recognition  of  pre-cancerous  conditions.  This  will  require  considerable  tact  in 
all  cases  and  an  excellent  beginning  would  be  made  by  securing  their  consent  to 
procure  and  distribute  Dr.  Greenough's  handbook  to  the  students  of  each 
senior  class. 

Those  conducting  courses  in  Public  Health  should  have  the  literature 
of  the  society  brought  to  their  attention  for  use  with  their  students. 

(f )  Public  Health  Association  when  formed. 

These  excellent  non-official  public  health  agencies  are  already  doing 
some  most  effective  work.  Where  such  associations  exist  they  should 
always  be  asked  to  cooperate  in  any  campaign  started  in  their  states  or  coun- 
ties. Made  up  as  they  are  of  representatives  of  all  health  and  civic  organiza- 
tions, together  with  prominent  members  of  Chambers  of  Commerce,  Rotary 
Clubs,  manufacturers'  associations,  labor  groups  and  representatives  of  the 
press,  the  cancer  campaign  could  be  conducted  by  them  (with  guidance)  ■in 
its  entirety. 

(g)  Association  of  Industrial  Physicians  and  Surgeons  when  formed. 

Such  associations,  together  with  all  other  organized  groups,  are  circular- 
ized from  time  to  time  from  the  office  of  the  National  Committee.  Much 
local  assistance  can  be  rendered  by  following  up  these  letters  and  applying  the 
suggestions  in  individual  plants. 


224  Hospital  and  Health  Survey 

2.  Activities  of  sub-committee  for  work  with  lay  or  non-professional  groups. 

(a)  Social  Workers. 

Contacts  should  be  formed  with  the  heads  of  all  charitable  organiza- 
tions doing  home  visiting  or  nursing  with  the  idea  of  instructing  these  social 
workers  in  regard  to  early  cancer,  in  order  that  they  may  be  in  a  position  to 
advise  properly  those  with  whom  they  come  in  contact. 

Associated  Charities,  and  similar  groups,  may  be  willing  to  cooperate 
in  arranging  for  public  meetings. 

(b)  Women's  Clubs. 

The  organized  women's  clubs  should  be  specially  urged  to  provide  for 
a  discussion  of  cancer  at  their  annual  meetings. 

The  local  clubs  should  prove  of  the  greatest  assistance  in  arranging 
public  meetings  of  women  to  be  addressed  by  qualified  physicians. 

Many  clubs  maintain  a  Public  Health  Committee  and  through  this 
much  valuable  cooperation  can  be  secured  by  public  meetings,  holding  ex- 
hibits, distributing  literature,  participating  in  special  "health  days,"  etc. 

(c)  Chambers  of  Commerce. 

The  Public  Health  Committee  of  the  Chamber  of  Commerce  should  be 
stimulated  to  give  the  cancer  control  program  attention  in  their  public  dis- 
cussions and  press  bulletins. 

Literature  on  the  subject  should  be  provided  for  distribution  to  their 
members  and  to  be  picked  up  by  visitors  to  their  rooms.  The  same  applies 
to  the  Men's  City  Club  and  to  the  Rotary  Club. 

(d)  Trades  Councils  and  Unions. 

These  industrial  groups  should  be  encouraged,  through  their  officers,  to 
allow  the  subject  to  be  discussed  at  some  of  their  meetings  and  be  provided 
with  literature  for  distribution. 

(e)  Ministerial  and  other  clerical  groups. 

These  influential  organizations  should  arrange  for  a  full  presentation 
of  the  subject  before  their  whole  membership. 

Opportunity  should  be  sought  to  have  the  cancer  control  progress  out- 
lined to  church  clubs,  men's  and  women's. 

Churches  will  often  cooperate  in  the  conduct  of  public  meetings. 

(f )  All  other  organized  groups  should  be  made  acquainted  with  the  purposes  of  the  society 
and  the  information  which  it  is  prepared  to  disseminate.  Some  of  the  other  organiza- 
tions which  readily  come  to  mind  are: 

Fraternal  Orders — Young  Men's  and  Young  Women's  Christian  Asso- 
ciations and  Young  Men's  and  Young  Women's  Hebrew  Associations. 


Private  Health  Agencies  225 

3.  Activities  of  Sub-Committee  on  Publicity. 

This  is  one  of  the  most  important  functions  of  a  local  committee  and  much  of  the 
success  of  the  campaign  will  depend  entirely  upon  the  efficiency  of  this  sub-committee. 
While  all  possible  avenues  of  publicity  cannot  be  covered,  some  of  the  obvious  methods  to 
follow  are: 

(a)  First  of  all  cultivate  a  personal  acquaintance  with  editors  of  the 
principal  newspapers. 

(b)  Offer  assistance  to  any  of  the  above  groups  planning  to  hold  meet- 
ings of  any  kind  on  cancer  by :  helping  to  prepare  material  for  announcement 
cards,  "throw-aways,"  window  posters,  newspaper  advertising,  etc.;  preparing 
and  sending  out  notices  to  be  read  in  churches,  lodges,  clubs  and  similar  places, 
and  by  assistance  in  every  way  in  calling  the  attention  of  the  public  to  the 
coming  meeting. 

(c)  Follow  up  every  meeting  held  by  sending  a  digest  of  it,  carefully 
prepared,  to  the  newspapers.  The  editor,  if  already  a  friend  of  the  move- 
ment, will  usually  send  a  competent  reporter  to  cover  an  important  meeting. 
No  chance  should  be  lost  to  get  into  the  good  graces  of  the  best  reporters,  for 
they  will  often  prepare  the  copy  themselves  if  they  feel  it  is  appreciated. 

(d)  Material  should  be  prepared  either  from  the  monthly  bulletin  of  the 
society  or  other  sources,  or  be  written  by  a  qualified  practitioner  connected 
with  the  society,  for  special  news  articles  or  editorial  comment  in  papers. 

(e)  Where  "Health  Columns"  are  run  by  papers,  encourage  the  editor 
to  devote  the  space  (or  part  of  it)  to  the  cancer  control  movement  from 
time  to  time.  If  it  is  run  in  the  nature  of  "Questions  and  Answers"  it  can 
be  used  to  great  advantage  by  asking  the  editor  leading  questions  on  the 
subject,  which  will  often  elicit  a  rather  thorough,  popular  discussion. 

In  addition  to  this  description  of  what  may  be  called  the  mechanics  of 
educational  publicity  there  is  an  opportunity  for  research  in  the  local  inci- 
dence, the  occupational  distribution  and  whatever  special  etiological  factors 
may  be  discovered  in  the  trades  and  industries  of  Cleveland. 

That  much  can  be  done  to  reduce  the  high  incidence  of  inoperable  cancer, 
no  one  doubts.  We  know  enough  about  the  subject  to  have  no  excuse  for 
our  silence.  Ignorance  of  the  resources  of  preventive  surgery  and  early 
diagnosis  is  a  direct  challenge  to  our  energy,  and  this  ignorance  is  wide- 
spread among  all  classes  of  the  population. 

THE  PREVENTION  AND  RELIEF  OF  MENTAL  DISEASE 

The  need  for  a  local  society  to  promote  the  interests  of  the  mental  hygiene 
movement  is  well  described  in  Part  VI.,  together  with  suggestions  for  suit- 
able activities.  The  Women's  Protective  League  is  the  only  private  agency 
dealing  with  any  phase  of  this  problem,  and  its  activities  are  confined  closely 
to  relations  with  court  cases  and  delinquency. 

THE  PREVENTION  AND  CONTROL  OF  VENEREAL  DISEASE 

The  work  to  be  done  by  a  local  society  along  lines  so  successfully  followed 
by  the  American  and  various  state  Social  Hygiene  Associations  is  described 
in  Part  V.  A  nucleus  for  such  an  organization  was  formed  in  Cleveland  and 
did  active  work  during  and  just  after  the  war.  It  should  be  revived  and 
resume  its  work. 


•226  Hospital  and  Health  Survey 


SUMMARY  OF  RECOMMENDATIONS 
Public  Health  Services: 

Any  repetition  of  the  numerous  suggestions  or  specific  recommendations  concerning 
the  personnel,  organization,  authority,  functions  or  performance  of  the  public  services 
which  have  been  analyzed  in  the  previous  pages  would  be  superfluous  for  those  whose 
interest  has  been  aroused  by  the  text. 

A  few  main  features  will  be  mentioned  to  call  attention  to  the  relative  importance  of 
the  recommendations  as  they  appear  to  the  members  of  the  Survey  staff. 

General  Administration 

Under  general  administration  it  is  considered  to  be  of  chief  importance  that  a  Com- 
missioner of  Health  be  appointed  whose  entire  time  may  be  devoted  to  his  duties  in  the 
Division  of  Health,  and  that  the  salary  be  adequate  to  demand  the  undivided  interest  of 
a  trained  sanitarian  (not  less  than  $7,500). 

Civil  service  appointments  for  the  entire  division  are  thought  to  be  essential  to  the 
best  service,  in  the  case  of  nurses,  the  Central  Nursing  Committee  to  be  the  agent  of  the 
Civil  Service  Commission  in  determining  fitness  of  applicants.  Medical  examination 
and  a  probation  period  of  three  months  for  all  employes  before  definite  acceptance  are 
advised. 

Sanitary  areas  as  defined  for  Cleveland  by  the  Bureau  of  the  Census  should  be  used 
as  the  basis  of  all  administrative  districts  for  health  work.  The  commissioner  should 
hold  regular  conferences  on  policies,  programs  and  results,  with  his  chiefs  of  bureaus.  The 
power  to  make  sanitary  rules  and  regulations  should  be  vested  in  an  advisory  board  of 
which  the  Commissioner  of  Health  is  a  member,  the  regulations  to  have  the  force  of  city 
ordinances. 

An  assistant  or  deputy  commissioner  should  have  in  charge  all  legal  actions  taken  at 
the  instance  of  any  of  the  bureaus  of  the  division. 

Bureau  of  Communicable  Disease 

The  control  of  the  communicable  diseases  of  animals  (other  than  those  used  for  slaugh- 
ter) should  be  vested  in  this  bureau. 

A  skilled  intubator  in  the  employ  of  the  Division  of  Health  is  considered  a  necessity 
for  emergency  work  in  diphtheria. 

The  service  of  the  district  physicians  would  be  greatly  improved  if  the  ten  recom- 
mendations presented  are  met. 

Bureau  of  Child  Hygiene 

The  thorough  consideration  of  the  Bureau  of  Child  Hygiene  in  Part  III.  makes  un- 
necessary any  statement  of  recommendations  here. 

Bureau  of  Sanitation 

The  needs  of  the  Bureau  of  Sanitation  are:  a  full-time  trained  chief  of  the  bureau, 
sufficient  sergeants  to  maintain  field  supervision  of  the  work,   and  the  assigning  of  all 


Summary  of  Recommendations  227 


sanitary  patrolmen  from  other  bureaus  to  work  under  the  direction  of  this  bureau,  in  small 
districts  where  they  may  cover  all  types  of  field  inspection,  functions  now  served  by  them 
for  any  bureau.  The  work  that  should  be  vigorously  prosecuted  by  this  bureau  includes 
enforcement  of  housing  regulations,  the  making  of  a  sanitary  survey  of  the  city  especially 
to  locate  all  privies,  private  water  supplies  and  stables. 

Bureau  of  Food  and  Dairy  Inspection 

The  Bureau  of  Food  and  Dairy  Inspection  should  modify  its  methods  for  milk  control 
to  make  use  of  the  bacterial  counts  of  milk  as  a  basis  of  exclusion  of  supplies.  There  should 
be  required  the  sterilization  of  containers,  discontinuance  of  holding  milk  after  pasteuriza- 
tion before  bottling,  and  a  standard  bottle  cap  to  indicate  the  place  and  date  of  production 
or  pasteurization  of  the  milk  and  the  grade.  No  milk  showing  counts  of  over  500,000 
bacteria  per  cubic  centimeter  in  the  pasteurized  product  should  be  allowed  on  sale  or  for 
distribution. 

Bureau  of  Laboratories 

The  Bureau  of  Laboratories  requires  the  undivided  attention  of  a  full-time  chief. 
This  bureau  should  be  relieved  of  its  inspectorial  functions.  Determination  of  meningo- 
coccus in  spinal  fluids  for  type,  and  of  pneumococcus  in  sputum  for  type  should  be  offered 
by  the  laboratory.  Specific  antisera  and  vaccines  of  proved  value  should  be  available 
through  this  laboratory.  Additional  activities  suitable  for  this  bureau  to  initiate  are 
proposed  in  the  special  chapter  on  "Patent  Medicines." 

Bureau  of  Vital  Statistics 

The  Bureau  of  Vital  Statistics  needs  a  full-time  trained  statistician  as  chief  to  inaugu- 
rate and  direct  to  completion  the  plan  of  work  presented  in  the  special  chapter  on  this 
subject. 

New  Activities 

New  activities  are  considered  essential  through:  the  appointment  of  a  Commissioner 
of  Publicity  and  Research  within  the  Department  of  Public  Welfare  to  inaugurate  and 
coordinate  facilities  for  health  education  in  Cleveland;  the  organization  of  a  bureau  of 
institutional  inspection  or  a  subdivision  of  an  existing  bureau  in  the  Division  of  Health, 
to  insure  adequate  sanitation  of  environment  and  medical  care  of  inmates  of  institutions; 
the  organization  of  a  bureau  of  industrial  hygiene  to  protect  employes  against  the  hazards 
of  their  occupations;  the  provision  of  a  corps  of  physicians  to  make  initial  medical  exami- 
nations of  all  city  employes  on  admission  to  the  city  service  and  periodic  re-examinations 
annually  thereafter;  the  organization  of  an  inspection  and  treatment  service  for  the  con- 
trol of  narcotic  drug  habitues  as  required  by  city  ordinance ;  assumption  by  the  Division 
of  Health  of  the  responsibilities  assigned  to  it  by  city  ordinance  in  the  supervision  over 
day  nurseries;  provision  for  sufficient  physicians  and  nurses  to  permit  of  inspection  of 
children  in  the  parochial  schools  in  a  manner  comparable  with  the  service  of  medical  pro- 
tection given  to  the  children  of  the  public  schools. 

The  Health  Centers  should  be  increased  in  number  to  sixteen,  with  appropriate  in- 
crease in  personnel  and  the  functions  served  in  these  district  offices  increased  to  cover  all 


228  Hospital,  and  Health  Survey 

field  services  of  the  Division  of  Health  and  to  provide  for  opportunities  for  including  the 
private  agencies  dealing  with  health  protection  and  for  affiliation  with  hospitals  and  dis- 
pensaries. 

The  coroner  system  should  be  abolished  and  the  system  of  medical  examiners  as  in 
existence  in  Boston  and  New  York  adopted. 

Private  Health  Agencies 

It  is  believed  to  be  of  great  importance  that  a  Cleveland  or  Cuyahoga  County  Public 
Health  Association  be  formed  to  give  direction  and  more  effectiveness  to  the  efforts  of  all 
the  public  and  private  agencies  in  this  field. 

A  secretary  for  health  to  act  as  advisor  in  health  problems  to  the  Director  of  the 
Welfare  Federation  is  advised. 

For  detailed  recommendations  dealing  with  the  activities  of  the  Anti-Tuberculosis 
League,  the  Visiting  Nurse  Association,  the  Association  for  Crippled  and  Disabled,  the 
Hospitals  and  Dispensaries  the  reader  is  referred  to  the  special  parts  and  chapters  devoted 
to  these  subjects. 

New  private  committees  or  agencies  are  urged,  so  that  public  interest  and  action  may 
be  developed  in  the  subjects  of  Prevention  and  Relief  of  Heart  Disease,  Prevention  and 
Control  of  Cancer,  Prevention  and  Treatment  of  Mental  Disease  and  for  the  Prevention 
and  Control  of  Venereal  Diseases,  for  all  of  which  projects  detailed  plans  are  presented  in 
the  appropriate  chapters. 


Appendix 


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Appendix 

TABLE  III. 
Communicable  Disease  Morbidity  Reports 

Disease  1919              1918              1917              1916 

Actinomycosis 0 

Anthrax 0 

Cerebro-spinal  Meningitis 73 

Chancroids 0 

Chickenpox 864 

Diphtheria 2,017 

Erysipelas 113 

Favus 0 

Gonorrhea 242 

Impetigo 95 

Infantile  Paralysis 10 

Influenza 4 ,  558 

Malaria  Fever 0 

Measles 2 ,  135 

Mumps 251 

Ophthalmia  Neonatorum 1 ,  140 

Pellagra 0 

Pneumonia 1 ,274 

Puerperal  Fever 0 

Rabies 2 

Scabies 30 

Scarlet  Fever 580 

Smallpox 232 

Syphilis 512 

Tetanus 9 

Tinea 4 

Tonsilitis 72 

Trachoma 30 

Trichinosis 0 

Tuberculosis 1 ,464 

Typhoid  Fever 80 

Typhus  Fever 0 

Whooping  Cough 634 

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Hospital  and  Health  Survey 


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Appendix 


237 


TABLE  VI. 


Report  of  District  Physicians — 1919 


Districts 

12  3  4  5 

Total  Patients 673  1,007  1,855  597  1,697 

Old ._. 135  14  201  34  114 

New 538  993  1,654  563  1,583 

Total  Calls     (On  the  above) 2,559  1,979  2,948  1,173  1,737 

Home 2,035  1,628  2,403  1,157  1,307 

Office 524  351  545  16  430 

Number  of  calls  per  case 3.8  1.96  1.58  1.96  1.02 

Miscellaneous,  not  included  in  the  above 

Wrong  address 26  7  91  41  26 

Not  found 25  12  77  40  15 

Not  ill 0  0  59  11  20 

Death  Certificates 55  51  66  118  62 

Contagious  Investigation 245  83  169  370  155 

Board  of  Education,  etc 169  0  0  181  76 

Vaccinations 4,523  474  949  1,554  5,129 

Disposal  of  Cases 

Continued 37  11  103  39  79 

Discharged : 247  846  1,564  392  1,059 

Died 13  10  32  5  5 

To  nurse 79  0  358  16  191 

To  hospitals 146  122  152  83  188 

To  dispensaries 129  31  127  42  60 

To  dentists 38  0  12  1  17 

To  private  physicians 0  0  0  21  13 

To  correctional  agencies 8  0  0  4  5 

To  relief  agencies 7  0  6  6  37 

Percent  of  total  cases  referred  to  hospitals 

dispensaries,  private  physicians 40.8  15.2  15.04  24.5  15.4 


Note 


Calls  out  of  district 

(Included  in  home  calls  above.) 


238 


Hospital  and  Health  Survey 


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240 


Hospital  and  Health  Survey 


TABLE  IX. 

Synopsis  of  Classified  Report  of  Bacteriological  Examination  of  Cleveland 

Market  Milk 

"The  age  of  the  milk  after  pasteurization  is  indicated  as  nearly  as  possible  by  "Fresh" 
if  less  than  24  hours  after  pasteurization,  and  by  "24  hours"  if  bottled  for  that  period  or 
longer. 


Group  I. — 12  samples: 

Class  A — 3  samples 
Class  B — 8  samples 
Class  C — 1  sample 


Group  II. — 54  samples: 

Class  A —  6  samples 
Class  B — 28  samples 
Class  C — 20  samples 


Group  III. — 34  samples: 


Class  A —  1 

sample 

Class  B — 18 

samples 

Class  C — 15 

samples 

Patron 

Milk 

Bacteria 

Patron 

Milk 

Bacteria 

Class 

Age 
Group  I. 
Class  A 

Count 

Class 

Age 

Group  II. 

Class  A 

Count 

Y. 

Fresh 

20,500 

Y. 

Fresh 

35,000 

X.Y. 

24  hrs. 

20,000 

X. 

Fresh 

32,000 

X. 

Fresh 

10,000 

X. 

Fresh 

16,000 

Y. 

Fresh 

2  spreaders 

Class  B 

Y. 
Y.Z. 

Fresh 
Fresh 

20,000 
19,000 

X.Y.Z. 

Fresh 

114,000 

X. 

Fresh 

116,000 

Class  B 

X. 

Fresh 

97,000 

X.Y.Z. 

Fresh 

109,000 

Z. 

Fresh 

224,000 

X.Y.Z. 

Store 

223,000 

Y. 

Fresh 

65,000 

Y.Z. 

Fresh 

70,000 

Y. 

Fresh 

72,000 

X.Y.Z. 

Fresh 

58,000 

X. 

Fresh 

115,000 

X. 

Fresh 

214,000 

Z. 

Fresh 

320,000 

Y. 

Fresh 

65,000 

Class  C 

Z. 
Z. 

Fresh 
Fresh 

120,000 
130,000 

Y. 

24  hrs. 

Over  500,000 

Y. 

Fresh 

225,000 

Appendix 


241 


Group  II. — (Continued) 

24  hrs.  490,000 

Fresh  256,000 

Fresh  107,000 

24  hrs.  15,000 

24  hrs.  117,000 

Fresh  35,000 

Fresh  95,000 

Fresh  234,000 

Fresh  56 , 000 

Fresh  261,000 

Fresh  108,000 

Fresh  55 , 000 

24  hrs.  95,000 

Fresh  74 , 000 

24  hrs.  420,000 

24  hrs.  400,000 

Fresh  •    60,000 

Fresh  104,000 

Fresh  115,000 

Class  C 


z. 

Fresh 

Over  500,000 

z. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

X. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

24  hrs. 

Over  500,000 

Y. 

24  hrs. 

Over  500 ,  000 

Y. 

24  hrs. 

Over  500 ,  000 

Z.Y. 

24  hrs. 

Over  500 ,  000 

Y. 

24  hrs. 

Over  500,000 

Y. 

24  hrs. 

Over  500,000 

Y. 

Fresh 

Over  500,000 

Y. 

Fresh 

Over  500 ,  000 

Z.Y. 

Fresh 

Over  500,000 

X. 

24  hrs. 

Over  500,000 

Y. 
Z. 
Z. 

z. 

Y. 

Y. 

Y. 

Z. 

Y.Z. 

Z. 

Z. 

Z. 

Y. 

Y. 

Y. 

Y. 

Z. 

X. 


X. 

Z. 

Z. 

Z. 

Z. 

Z. 

Z. 

Y. 

Z. 

Z. 

Z. 

Z. 

Y.Z. 

Y. 

Y. 


Group  III 

Class  A 

Fresh 

26,000 

Class  B 

Fresh 

150,000 

Fresh 

300,000 

Fresh 

91,000 

Fresh 

1,000 

Fresh 

210,000 

24  hrs. 

97,000 

Fresh 

143 , 000 

Fresh 

7,000 

Fresh 

71,000 

Fresh 

55,000 

Fresh 

140,000 

24  hrs. 

135,000 

Fresh 

434,000 

24  hrs. 

156,000 

Fresh 

95,000 

Fresh 

180,000 

Fresh 

109,000 

Fresh 

136,000 

Class  C 

Fresh 

Over  500,000 

Fresh 

Over  500 ,  000 

Fresh 

Over  500,000 

Fresh 

Over  500 ,  000 

Fresh 

Over  500,000 

Fresh 

Over  500,000 

Fresh 

Over  500,000 

Fresh 

Over  500,000 

24  hrs; 

Over  1 ,  000 ,  000 

Fresh 

Over  500 ,  000 

Fresh 

Over  500 ,  000 

Fresh 

Over  500,000 

Fresh 

Over  500,000 

24  hrs. 

Over  500,000 

24  hrs. 

Over  500,000 

242 


Hospital  and  Health  Survey 


Reference  Tables  on  the  Movements  of  the  Population 

of  Cleveland  * 

TABLE  X. 

Rank  and  growth  of  the  population  of  Cleveland,  in  comparison  with  twenty 

other  cities,  1900  to  1920 


1920 

1910 

1900 

City 

Population 

Rank 

Population 

Rank 

Population 

Rank 

Cleveland.  _    

New  York 

Chicago. 

Philadelphia 

Etc 

This  table  is  intended  for  census  years  primarily  but  may  be  used  for  intercensal 
years  on  the  basis  of  Census  Bureau  estimates. 


TABLE  XI. 

Principal  color,  nativity  and  parentage  classes  of  the  population.    Percentage 
of  total, -and  rate  of  growth  of  each  class,  1900  to  1920 


1920 

1910 

Class  of  Population 

Popula- 
tion 

Per  Cent 
of  Total 

Per  Cent 

Increase 

Since  1900 

Popula- 
tion 

Per  Cent 
of  Total 

Per   Cent 

Increase 
Since  1900 

Total 

White- 
Native-born — 

Of  native  parentage.... 

Of  for.  or  mxd.  ptge. 
Foreign-born 

Negro 

Other  Colored — 

Chinese 

Japanese 

Others  of  this  class 

This  table  is  intended  for  census  years  primarily  but  may  be  used  occasionally  for 
intercensal  years  for  the  calculation  of  differential  birth  rates  and  death  rates  for  each 
class  of  the  population. 

*  In  such  of  the  following  tables  as  subdivisions  of  the  city  are  used  for 
the  tabulation  of  population,  morbidity,  mortality,  etc.,  it  is  recommended 
that  the  sanitary  areas  (131),  as  established  by  the  Bureau  of  the  Census  for 
Cleveland,  be  used  in  preference  to  wards  or  other  political  or  administrative 
districts  of  the  city's  area.  This  will  affect  Tables  XV.,  XVII.,  XX.,  XXI., 
XXII.,  XXVII.,  XXXIII.,  XXXV..  XXXVI. 


Appendix 


243 


TABLE  XII. 

Number  and  percentage  of  population  in  each  age  period,  by  sex,  1910  and  1920 


1920 

1910 

Age 

Males 

Females 

Males 

Females 

No. 

Per  Cent 

No. 

Per  Cent 

No. 

Per  Cent 

No. 

Per  Cent 

Total 

Under  5 

Under  1 

1 

2 : 

3 

4 

5  to  9 

Etc.,  to  95  and  over... 

For  census  years  primarily,  but  should  be  used  also  intercensally  to  show  the  basis  for 
age,  death  rates  and  also  for  fecundity  rates;  f. «.,  births  per  1,000  women  at  the  child- 
bearing  ages,  15  to  45  years. 


TABLE  XIII. 

Number  and  percentage  of  population  in  specified  marital  condition  classes, 

by  sex  and  age,  1920 


Total 

Single 

Married 

Widowed 

Divorced 

Age  Period  and  Sex 

No. 

Per  Cent 

No. 

Per  Cent 

No. 

Per  Cent 

No. 

Per  Cent 

No. 

Per  Cent 

15  years  and  over — 

100.0 
100.0 

Female 

15  to  24  years 

Male.  .._ 

Female 

25  to  44  years 

Male... 

Female 

45  to  64  years 

Male. _ 

100.0 
100-.0 

100.0 
100.0 

100.0 
100.0 

100.0 
100.0 

Female... 

65  years  and  over 

Male 

Female 

This  is  for  the  census  years  only  and  the  figures  may  be  made  the  basis  of  the  calcula- 
tion of  death  rates  by  sex  and  marital  condition  at  each  age  period. 


244 


Hospital  and  Health  Survey 


TABLE  XIV. 

Country  of  origin  of  the  foreign  white  stock  in  the  population  of  Cleveland 


Foreign 
Born 
White 

Native  White  of  Foreign 
or  Mixed  Parentage 

Country  of  Origin 

Total  Foreign 
White  Stock 

Total 

Both 
Parents 

One  Parent 

Number 

Per  Cent 

Born  in 
Specified 
Country 

Native,  Other 
Born  in  Speci- 
fied Country* 

100   0 

(List  countries  here) 
Foreign  or  mixed  Parentage* 

*For  native  whites  whose  parents  were  born  in  different  foreign  countries  included  in  last  line. 

This  table  is  intended  for  census  years  only  and  may  be  made  the  basis  of  computa- 
tion of  death  rates  in  1920  of  the  various  foreign  born  stocks  in  the  city. 

TABLE  XV. 

Ward  or  "sanitary  district"  population  of  the  city  of  Cleveland,  1920 


Item 

Total  City 

Ward  or  Sanitary  District 

1 

2 

3 

4 

Etc. 

Total  population — 

Male 

Female 

White- 
Native-born 

Of  native  parentage 

Of  for.  or  mxd.  ptge. 

Foreign-born 

. 

s 

Negro.... 

Chinese  and  Japanese 
Foreign-born  white 

Born  in 
(List  countries  here) 

Land  area  (acres) 

Persons  per  acre .- 

Dwellings    (number) 

i, 

Families  (number) 

Persons  per  family 

This  table  is  for  census  years  only  and  may  be  used  as  a  basis  for  educational  and 
Americanization  work,  especially  in  those  wards  where  the  foreign-born  live.  Transit 
and  park  facilities  may  also  be  gauged  therefrom. 


Appendix 


245 


TABLE  XVI. 

Number  of  persons  10  years  of  age  and  over  gainfully  employed  in  specified 
occupations.     By  sex  and  age. 


Total 

Males 

Females 

Occupation 

Total 

10  to  16 

16  to  19 

Etc. 

Total 

10  to  16 

16  to  19 

Etc. 

All  occupations 

(Abbreviated  list 

of  occupations 

and    industries — 

about  50  titles) 

This  table  is  for  census  years  only.  It  is  planned  also  to  tabulate  the  occupations 
of  the  deceased  of  1920  in  a  similar  manner  to  permit  the  computation  of  death  rates  for 
the  more  important  occupations  of  the  city. 

TABLE  XVII. 

Estimated  population  of  the  city  of  Cleveland  and  of  its  subdivisions,  1920  to  192 — 


Ward  or  Sanitary  Area 

1925 

1924 

1923 

1922 

1921 

1920 

1910 

Total _ 

Ward  1 

Ward  2 

Ward  3 

Etc 

This  table  is  required  each  year  and  is  based  on  arithmetic  increase  of  population 
during  the  last  decade.  If  this  can  be  proved  reliable,  it  becomes  the  denominator  of 
all  important  measures  of  the  movement  of  population  in  each  ward  of  the  city,  including 
marriage  rates,  birth  rates,  death  rates,  sickness  rates,  etc. 

TABLE  XVIII. 

Number   of  livebirths  and  birth  rates  (a)  per  1,000  of  total  population,  and 
(b)  per  1,000  women  of  childbearing  age 


(1) 

Year 

(2) 
Births 

(3) 

Birth  Rate 
per  1,000 

(4) 

Birth  Rate 

per  1,000 

Women  15-44 

(5) 
Number  of 
Stillbirths 

(6) 

Per  Cent  Stillbirths 

of  Total  Live  and 

Stillbirths 

1925....; 

1924 

1923 

1922 

1921 

1920 

This  is  a  permanent  table  and  may  be  used  to  advantage  to  detect  the  trend  of  the 
birth  rate  and  to  control  the  waste  of  stillbirths  which  may  be  looked  upon  as  an  impor- 
tant element  in  infant  mortality. 


246 


Hospital  and  Health  Survey 


TABLE  XIX. 

Number  of  livebirths,  by  sex  of  cbild,    color  and  nativity  of  parents,  each 

month  in  192— 


Month 
(1) 

Total 
(2) 

Parent  Nativity  and  Color 

Sex  of  Child 

White 

Col- 
ored 

(8) 

Color 

For- 
eign 

(5) 

Both 

Parents 

Native 

(6) 

One  Parent 

Native,  Other 

Foreign 

(7) 

Unknown 

Male 
(3) 

Female 
(4) 

(9) 

Total  year._. 

January.... 

February.. 

March   .. 

April 

May 

Etc 

This  table  is  permanent  and  should  be  the  basis  of  infant  welfare  work  by  depart- 
mental agencies,  such  as  clinics,  visiting  nurses,  etc. 


TABLE  XX. 

Number  of    livebirths  by  nativity  of  white    mothers  in  specified  wards,  192 — 


Country  of  Birth  of  Mother 
of  Child 

Total  City 

Ward  1 

Ward  2 

Ward  3 

Etc. 

United  States 

Great  Britain 

Etc 

This  table  supplements  the  following  one  and  is  especially  useful  to  determine  the 
educational  work  required  to  obtain  the  cooperation  of  mothers  for  better  obstetrical 
service,  clinic  attendance,  etc. 


Appendix 


247 


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248 


Hospital  and  Health  Survey 


TABLE  XXII. 

Number  of  livebirths  in  specified  districts  by  calendar  months 


Ward  or  Sanitary  Area 

Total  Year 

Jan. 

Feb.      |     Mar. 

i 

Apr. 

Etc. 

Total 

Ward  1 

Ward  2 

Ward  3 

Etc 

P  This  table  will  prove  a  useful  check  on  the  attendance  of  mothers  at  maternity  and 
infant  welfare  stations  in  the  various  sections  of  the  city  during  the  course  of  the  year. 

TABLE  XXIII. 

Illegitimate  births  by  color  and  nativity  of  parents,  192 — 


Total 

WHITE 

Colored 

Color 

Ward  or  Sanitary  Area 

Foreign 
Born 

Native 

Unknown 

Both 
Parents 
Native 

One  Parent 

Native, 

Other  Foreign 

Total       

Ward  1 

Ward  2 

Ward  3 

Etc. 

This  table  may  be  tried  out  for  one  or  two  years  for  the  city  as  a  whole.  If  returns 
are  fairly  complete,  the  fuller  tabulation  by  wards  may  be  given.  This  may  prove  to  be 
a  very  useful  instrument  for  the  social  service  agencies  of  the  city  in  indicating  where 
illegitimacy  prevails  and  the  peoples  who  contribute  most  to  this  problem.  The  figures 
will  serve  also  to  compute  the  infant  mortality  rate  of  illegitimate  children. 

TABLE  XXIV. 

Deaths  of  infants  under  one  year  of  age.     Principal  causes  of  infant 
mortality,  by  wards,   192 — 


Cause  of  Death 

Total 

Ward  1 

Ward  2 

Ward  3 

All  causes 

Abridged  list  of  causes 

This  table  is  permanent  and  is  the  keystone  of  the  whole  plan  of  infant  welfare  work 
of  the  department.  It  determines  where  the  chief  infant  mortality  occurs  and  the  causes 
of  such  mortality,  whether  from  diarrheal,  respiratory,  or  other  infections,  a  preventable 
disease,  or  particularly  from  congenital  causes  indicating  poor  obstetrical  or  prenatal  service. 


Appendix 


249 


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250 


Hospital  and  Health  Survey 


TABLE  XXVI. 

Deaths  of  infants  under  one  year  of  age,  by  calendar  months  and  by  causes  of 

infant  mortality,  192 — 


Cause  of  Death 

Total  Year 

Jan.          Feb. 

Mar. 

Apr. 

Etc. 

All  causes 

(Ten  abridged  list  of 
causes) 

This  table  supplements  table  XXIV.  and  locates  the  departmental  service  to  be  ren- 
dered in  time  of  year. 

TABLE  XXVII. 

Deaths  of  infants  under  one  year  of  age,  per  1,000  livebirths  (infant  mortality 
rates).     For  principal  causes  of  death.     By  specified  districts. 


Cause  of  Death 

Total  City 

District  1 

District  2 

District  3 

Etc. 

All  causes 

(Then  abridged  list) 

This  table  is  a  composite  of  tables  XX.  and  XXIV.  above.  The  rates  are  more 
definite  than  the  absolute  numbers  of  table  XXIV.  in  indicating  where  conditions  are 
most  serious — although  the  figures  of  the  previous  tables  must  be  used  as  well  to  show 
the  size  of  the  problem  in  each  area. 


TABLE  XXVIII. 

Deaths  and  death  rates  per  100,000  from  principal  diseases  in  Cleveland 


Cause  of  Death 

No.  of  Deaths 

Death 
100,000 

19— 

Rate  per 
Population 

1915-1919 

All  causes  of  death 

(Then  give  detailed  list  of  causes  of  death) 

This  is  a  permanent  table  and  fundamental  to  the  work  of  the  health  department. 
It  indicates  what  diseases  and  conditions  are  especially  serious  in  the  mortality  experience 
of  the  city.  The  comparison  between  the  year  in  question  and  the  previous  five-year 
period,  1915  to  1919,  indicates  the  trend  of  the  death  rate  for  the  several  causes. 


Appendix 


251 


TABLE  XXIX. 

Number  of  deaths  from  principal  causes  of  death,  by  age  period 


Cause  of  Death 

All 
Ages 

Under  1 

1 

2 

3 

4 

Total 
Under  5 

5  to  9 

Etc. 

All  causes — total 

(Detailed  list  of  causes  of 
death) 

This  table  supplements  table  XXVIII.  and  indicates  the  age  periods  wherein  most  of  the 
deaths  occur  from  each  of  the  causes.  These  two  tables  will  serve  to  formulate  the  gen- 
eral policy  of  the  department  in  its  attack  on  the  more  important  diseases  and  conditions. 
They  both  cover  the  city  as  a  whole.  • 


TABLE  XXX. 

Number  of  deaths  from  principal  diseases  in  wards  during  192- 


Cause  of  Death 

Total  City 

Ward  1 

Ward  2 

Etc. 

All  causes  of  death 

(Then  abridged  list  of  causes  of  death) 

This  table  shows  the  wards  in  which  the  problems  outlined  in  the  previous  two  tables 
may  be  more  profitably  attacked. 


TABLE  XXXI. 

Number  of  deaths  from  principal  diseases,  by  calendar  months 


Cause  of  Death 

Total  Year 

Jan. 

Feb. 

Mar. 

Apr. 

May 

Etc. 

All  causes — total 

(Then  abridged  list  of  causes 
of  death) 

This  table  will  direct  the  attention  of  the  health  officer  to  the  months  of  the  year  in 
which  more  of  the  preventable  diseases  cause  death.  Campaigns  of  control  may  thus  be 
prepared  and  instituted  prior  to  the  period  of  highest  incidence. 


252 


Hospital  and  Health  Survey 


TABLE  XXXII. 

Deaths  and  death  rates  per  100,000,  by  sex  and  by  age,  1920 


MALES 

FEMALES 

AGE 

Population 

Deaths 

D.  R.  Per 

100,000 

Population 

Deaths 

D.  R.  Per 
100,000 

All  ages.. 

Under  1 

1  to  4 

5  to  9  

10  to  14 : 

15  to  19 

20  to  24 

25  to  34 

! 

35  to  44 

45  to  54 ... 

55  to  64 

65  to  74 

75  and  over. 

This  table  is  intended  for  use  only  in  census  years  and  points  out  the  conditions  of 
mortality  in  each  sex  in  the  various  age  periods  of  life.  Its  greatest  use  will  consist  in 
giving  the  basis  for  the  construction  of  decennial  life  tables. 


TABLE  XXXIII. -A,  B,  C,  Etc. 

Deaths  and  death  rates  per  100,000,  from  certain  diseases,*  by  wards  or  sanitary 
districts,  for  years  1915  to  1919 


192— 

1915-1919 

Ward 

Deaths 

Death  Rate 

Deaths 

Death  Rate 

Total  city 

Ward  1 « 

Ward  2  

Etc 

| 

•Typhoid,  tuberculosis,  measles,  scarlet  fever,  whooping  cough  or  other  diseases. 

Table  XXXIII.  is  one  of  a  series,  each  one  relating  to  a  cause  of  death,  such  as  typhoid 
fever,  tuberculosis,  whooping  cough,  measles,  scarlet  fever,  diarrhea  and  enteritis,  automobile 
accidents  and,  in  fact,  any  other  condition  which  is  subject  to  the  control  of  the  health 
authorities.  The  figures  indicate  the  number  of  deaths  annually  and  the  death  rate  in 
each  one  of  the  several  wards  of  the  city.  Comparison  with  the  five-year  period,  1915 
to  1919,  makes  it  possible  to  determine  the  effectiveness  of  the  control  against  the  diseases 
in  each  of  the  several  wards. 


Appendix 


253 


TABLE  XXXIV. 

Number  of  deaths  of  persons  in  specified  color,  nativity  and  parentage 
classes,  by  sex  and  age 


Color,  Nativity,  Parentage 


All 
Ages 


Under 

1 


Under 
5 


Total — 

Male... 

Female 

White— total 

Male 

Female 

Native-born — 

Male 

Female 

of  native 

parentage — 

Male 

Female 

of  foreign 

and    mixed    par- 
entage— 

Male 

Female 

Foreign-born — 

Male 

Female 

Colored — total 

Male 

Female 

Negroes — 

Male 

Female 

Other  Colored — 

Male 

Female 


This  table  will  be  most  useful  for  census  years,  although  it  should  be  available  for 
intercensal  years  as  well  as  a  reference  table.  Coupled  with  the  data  available  in  the 
census  publications,  it  will  make  possible  the  construction  of  life  tables  for  each  one  of 
the  chief  classes  of  population. 


254 


Hospital  and  Health  Survey 


TABLE  XXXV. 

Cases  and  deaths  from  notifiable  diseases,  by  wards  or  sanitary  areas,  192 — 

Total  City 

Ward  1 

Ward  2 

Disease 

Cases 

Deaths 

Cases 

Deaths 

Cases 

Deaths 

Etc. 

Typhoid  fever 

Etc. 

This  table  should  be  available  not  only  annually  but  for  shorter  periods,  perhaps 
monthly,  and  certainly  quarterly.  It  indicates  where  the  notifiable  diseases  are  prevalent 
and  shows  also  from  the  relation  of  cases  to  deaths  how  serious  the  cases.  An  additional 
column  may  be  added  to  show  the  lethal  rate  for  each  one  of  the  diseases. 

TABLE  XXXVI.-A,  B,  C,*  Etc. 

Cases  of  notifiable  disease  in  each  ward  or  sanitary  area,  by  calendar  month,  192 — * 


Year 

Total  Year 

Jan. 

Feb. 

Mar. 

Apr. 

May 

Etc. 

Total... _ 

Ward  1 

Ward  2 

Etc. 

*One  table  for  each  disease 

Table  XXXVI.  supplements  table  XXXV.  and  indicates  the  seasonal  distribution  of 
the  several  notifiable  diseases  in  each  ward.     This  is  an  annual  table. 


TABLE  XXXVII. 

Number  of  marriages  and  divorces  and  rate  per  1,000  of  population  by  month 


Marriages 

Divorces 

Month 

Number 

Rate  per  1,000 
of  Population 

Number 

Rate  per  1,000 
of  Population 

Year 

January 

February 

March 

April 

May 

June 

July _ 

August 

September 

October 

November 

December 

Appendix 


255 


TABLE  XXXVIII. 

Number  of  marriages  by  age  of  groom  and  bride 


Age  of  Bride 

Age  of 
Groom 

All 

ages 

Under 
20 

20 
to 
24 

25 
to 
29 

30 
to 
34 

35 
to 
39 

40 
to 

44 

45 
to 
49 

50 
to 
54 

55 
to. 
59 

60 
to 
64 

65 
to 
69 

70 
to 

74 

75 
to 
79 

80 

to 

over 

All  ages 
Under  20.... 
20  to  24 
25  to  29 
30  to  34 
35  to  39 
40  to  44 
45  to  49 
50  to  54 
55  to  59 
60  to  64 
65  to  69 
70  to  74 
75  to  79 
80  and  over 

TABLE  XXXIX. 
Results  of  Medical  Examinations  of  Children  in  Institutions 


Capacity 

Cleveland  P.  O.  Asylum 68 

St.  Joseph's  Orphan  Asylum 236 

Cleveland  Christian  Orphanage ^ 46 

House  of  the  Holy  Family 37 

Detention  Home 104 

Jewish  Infant  Orphan  Asylum 72 

Jewish  Orphan  Asylum 473 

Mount  St.  Mary's 152 

St.  Ann's  Infant  Asylum-. 100 

St.  John's  Orphanage 20 

Jones  Home 75 

St.  Vincent's  Orphan  Asylum 236 

House  of  the  Good  Shepherd 185 

Salvation  Army  Rescue  Home 17 

Children's  Aid  Society 103 

Holy  Ghost  Orphanage 14 

Girl's  Farm 42 

Training  School  for  Friendless  Girls 30 

Catherine  Horstmann  Home 22 


Children 
Examined 

Found 
Normal 

to  have 

one  or  more 

defects 

22 

1 

21 

41 

1 

40 

9 

1 

8 

10 

0 

10 

16 

0 

16 

12 

0 

12 

74 

3 

71 

25 

1 

24 

15 

1 

14 

6 

3 

3 

12 

1 

11 

38 

0 

38 

34 

0 

34 

4 

0 

4 

24 

2 

22 

4 

0 

4 

10 

0 

10 

9 

0 

9 

6 

0 

6 

Total  Institutions — 19. 


2,032 


371 


14 


357 


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Appendix 


257 


No.  of 
Institutions 

Overcrowding '. —  6 

Building  not  screened 3 

Sexes  not  separated 2 

No  play  ground 1 


TABLE  XLI. 

Sanitary  Summary 

Inadequate  fire  protection 12 

No  fire  drills 9 

Improper  fire  escapes --  8 

No  regular  fire  drills.. .— - 8 

Fire  extinguishers  unfit... 4 

Obstructed  fire  escapes.... — 2 

No  fire  extinguishers — - 1 


Children,   two  in  a  bed 7 

Improperly  placed  beds.. — 4 

Improper  bed  springs..... 3 

Wooden  beds. — 2 

Unclean  bed  linen 1 

Clothing  used  in  common —  2 

Donated    clothing    used    without    first 
washing  it — -  1 

Soap  used  in  common 18 

Common  roller  towel.. 9 

Individual  towels  and  wash  cloths  not 

provided -  8 

Individual  combs  and  hair  brushes  not 

provided. - — 8 

Inadequate  lavatory  and  toilet  facili- 
ties...  - — -  7 

Unsanitary  toilets —  4 

Inadequate  bathing  facilities... 4 

Several  children  bathed  simultaneously 

in  same  tub 3 

Common  toilets  for  both  sexes — 2 

Dirty  wash  basins -  2 

No  drinking  fountains '. 9 

Common  drinking  cups 8 


Leaky  plumbing 5 

Enclosed  plumbing -  2 

Inadequate  light  in  classrooms 8 

Inadequate  light  in  toilets —  3 

Inadequate  light  in  playrooms 2 

Poor  ventilation  in  toilets 11 

Poor  ventilation  in  other  rooms 8 

Unventilated  closets.. — 2 

Poor  ventilation  in  schoolroom 1 

Poor  ventilation  in  playroom 1 

Improper  refrigeration  of  food 7 

Worn  oilcloth  on  dining  room  tables. 4 

Kitchen  tables  not  zinc  covered 4 

Unguarded  laundry  and  other  machin- 


ery. 


Dry  sweeping - 6 

Defective  plastering -  -  4 

Defective  flooring.. 4 

Backless  benches  used  in  classroom 5 

Unsanitary  school  desks 2 


258 


Hospital  and  Health  Survey 


TABLE  XLII. 

SUMMARY   OF  PHYSICAL   EXAMINATION   OF  BOARDED-OUT   CHILDREN 

Total  number  examined — 57.     Normal — 4.     Defective — 53. 


o  £        ,     "5  j«  '2  "5  "5  E  j=> 

.2  «  S  ™  u  O  3  to  3  t.  u 

>KH!SfflH  2  U  0,  O  £ 

7  0  28  29  24  26  3  3  20  0 

Miscellaneous  Defects 

Cervical  Glands..... _ 23 

Conjunctivitis 1 

Ringworm 1 

Enlarged  Thyroid 2 

Adenoids.... 1 

Epitrochlear  Glands 1 

29 

The  sanitary  conditions  in  these  boarding  homes  were  not  included  in  this  study. 


29 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIH.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.    Nursing. 

X.     Hospitals  and  Dispensaries. 

XI.     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 

The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 

THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Pbemibr  Presb 

Cleveland,  O. 


A  Program  for 
Child  Health 


Part  Three 


Cleveland     Hospital     and 
Healtn     Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -  Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

TheT  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work' and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director 

and  the  following  collaborators: 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 
Josephine  Goldmark,  A.  M.,  Director  of  the  Nursing  Survey; 
Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 
S.  Josephine  Baker.,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 

and  Maternity  Survey; 
T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 
W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 
Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

Page 

I.    Present  Organization 267 

II.    The  Problem 269 

III.  Proposed  Organization .....  270 

IV.  Functional  Activities 

Prenatal  Care.. 273 

Maternity  Care 275 

Infant  Care 280 

Pre-School  Age  Care 284 

Child-caring  Institutions _____ 287 

Children's  Dispensaries 288 

Schools 

Health  Supervision . 288 

Sanitary  Supervision _ 297 

Recommendations ___ 301 

Issuance  of  Work  Certificates 318 

V.    Conclusions _ 319 


A  Program  for  Child  Health  Work 
in  Cleveland 

By  Josephine  Bakes,  M.  D.,  D.  P.  H. 

"The  aim  of  hygiene  in 
general  is  to  render 
growth  more  perfect, 
decay  less  rapid,  death 
more  remote  and  life 
more  vigorous  and  suc- 
cessful." 

IN  presenting  a  program  for  future  child  health  work  in  Cleveland,  it  has 
been  considered  essential,  first,  to  analyze  the  work  as  it  is  carried  on 
at  the  present  time;    second,  to  discuss  certain  basic  needs,  and  third, 
to   suggest   measures  that   should   be   instituted   to   obtain   more   effective 
results. 

Present  Organization 

The  survey  has  emphasized  the  lack  of  strong  central  control  and  effec- 
tive coordination  of  the  activities  for  child  welfare  as  a  whole.  Public  and 
private  agencies  are,  in  many  instances,  carrying  on  service  of  excellent 
quality  and  distinct  merit,  but  these  activities  are  limited  in  extent  and, 
with  one  possible  exception  (the  hospital  maternity  service)  they  are  inade- 
quate to  meet  the  self-evident  needs  of  the  child  population  of  Cleveland. 
The  lack  of  coordination  by  each  agency  with  other  agencies  or  as  part 
of  the  child  health  program  of  the  community,  and  the  absence  of  a  definite 
program  for  continuous,  adequate  and  progressive  action,  are  detrimental 
to  the  full  effectiveness  of  each  group.  Some  of  the  children  of  Cleveland 
are  receiving  at  certain  periods  of  their  growth  a  type  of  care  that  is  excel- 
lent and  should  be  commended,  but  the  unrelated  functions  of  the  various 
child  hygiene  activities  have  left  children  as  a  whole  without  that  con- 
tinuous oversight  which  alone  can  guarantee  the  type  of  good  health  that 
will  serve  throughout  life. 

With  the  exception  of  the  prenatal  work  and  certain  parts  of  the  work 
carried  on  in  the  prophylactic  baby-health  stations,  the  Survey  would  seem 
to  show  that  there  is  lack  of  preventive  health  functions.  Emphasis  has 
been  placed  on  corrective  work  and  there  is  too  great  a  tendency  to  view 
the   immediate   results   as   justifying   or   proving   the   effectiveness    of   the 

*For  the  collection  of  the  information  from  which  this  report  was  prepared  the  author  is  indebted  to 
many  of  her  colleagues,  and  their  assistants,  in  the  other  subjects  of  the  Survey.  The  author  wishes  to 
express  her  appreciation  particularly  for  the  studies  contributed  by  Gertrude  Sturges,  M.  D.,  Michael 
Davis,  Ph.  D.,  Anna  Richardson,  M.  D.,  Miss  Josephine  Goldmark,  Miss  Elizabeth  Fox,  Miss  Janet 
Geister  and  Miss  Florence  V.  Ball. 


L268  Hospital  and  Health  Survey 

methods  employed.  Intensive  effects  often  unconsciously  interfere  with 
proper  perspective.  Extreme  specialization  has,  in  some  instances,  resulted 
in  too  great  concentration  upon  the  activity  and  not  enough  upon  the  child 
as  a  whole.  Treating  disease  is  essential.  Removing  diseased  tonsils  and 
filling  decayed  teeth  are  important  activities,  but  the  full  fruition  of  normal 
and  sound  health  cannot  be  achieved  by  these  methods  alone,  however  well 
they  may  be  performed.  The  admirable  work  that  is  being  carried  out 
should  receive  its  full  measure  of  praise.  On  the  other  hand,  we  cannot 
ignore  the  fact  that  the  present  facilities  are  inadequate  in  extent,  that  in 
some  instances  they  are  not  functioning  effectively,  and  that  the  lack  of 
unity  of  purpose  and  central  control  has  resulted  in  markedly  lessening  the 
results  that  might  reasonably  be  expected  from  the  amount  of  effort  that 
has  been  put  into  the  work  as  it  is  carried  on  at  the  present  time. 

There  are  two  fundamental  bases  for  effective  child-hygiene  work  in 
any  community: 


First — Object:  Prevention  of  disease  is  the  first  consideration,  with  such 
corrective  health  measures  as  may  be  necessary  to  assure  a  normal 
physique  during  childhood  and  sound  health  throughout  adult  life. 

Second — Method:  Continuous  coordination  and  effective  health  super- 
vision from  the  prenatal  period  through  adolescence,  by  means  of  public 
and  private  community  provision  of  all  essential  educational  and  health 
aids,  including  health  instruction,  supervision  and  care  of  the  indi- 
vidual mother  and  child. 


Cleveland's  problem  does  not  differ  from  that  of  other  communities  in 
this  regard.  Mention  should  be  made  of  the  efforts  which  are  directed 
toward  meeting  the  situation.  Praise  should  be  given  to  the  four  great 
features  of  Cleveland's  child-caring  program:  (1)  The  prenatal  and  maternity 
services  for  expectant  mothers,  originating  in  the  work  of  the  Maternity 
Hospital,  and  now  shared  in  by  other  hospital  and  nursing  agencies;  (2)  The 
Babies'  Dispensary,  which  serves  the  whole  city  in  the  diagnosis  and  treat- 
ment of  the  ills  of  infancy;  (3)  The  prophylactic  baby  health  stations  of  the 
Division  of  Health,  which  serve  by  teaching  mothers  how  to  keep  well  babies 
well;  (4)  The  system  of  school  medical  inspection,  under  the  Board  of  Edu- 
cation. A  creditable  infant  mortality  rate  and  a  widespread  public  interest 
in  the  necessity  for  correction  of  physical  defects  and  the  resources  for  main- 
taining children's  health  are  the  logical  results  of  these  activities.  It  is 
evident,  however,  that  there  are  many  gaps  in  the  continuity  of  an  effec- 
tive health  program  for  children.  There  is  not  only  lack  of  coordination 
in  the  work  of  the  agencies  in  the  field  but,  in  many  instances,  there  are 
insufficient  equipment  and  personnel  to  meet  existing  needs  in  a  manner 
at  all  adequate. 


A  Program  for  Child  Health  269 


The  Problem 

Concretely,  the  problem  in  Cleveland  may  be  outlined  as  follows: 

1.  There  are  approximately  240,000  children  in  Cleveland  under  sixteen 
years  of  age. 

2.  There  were  19,123  registered  births  in  Cleveland  during  1919.  Con- 
servatively estimated,  fifty  per  cent  or  ten  thousand  of  these  mothers 
require  medical  and  nursing  supervision  and  care,  at  the  expense  of  the 
community,  during  their  prenatal  period  and  at  time  of  confinement, 
and  an  equal  number  of  babies  need  care  during  the  period  of  infancy. 
It  is  estimated  that  the  remaining  fifty  per  cent  are  able  to  obtain  the 
essential  care  through  individual  effort,  although  a  relatively  small  pro- 
portion of  the  latter  group  actually  receive  what  is  recognized  as  ade- 
quate prenatal  care. 

3.  On  the  basis  of  an  estimation  of  approximately  twenty  thousand  children 
in  each  year  age-group  under  five  years,  it  is  probable  that  there  are 
about  sixty  thousand  children  between  two  and  five  years  of  age  in  Cleve- 
land. From  experience  with  this  age-group  in  other  cities,  it  is  esti- 
mated that  at  least  thirty  thousand  of  these  children  need  the  type  of 
health  supervision  they  can  obtain  only  through  concerted  action  of 
community  forces. 

4.  To  the  number  of  children  attending  the  public  schools  (103,273,  not 
including  students  in  Senior  High  Schools)  should  b*e  added  the  full  number 
in  attendance  at  the  other  free  schools  in  the  city  (35,000,  in  the  parochial 
schools),  whether  under  denominational  or  other  control.  In  its  expen- 
diture for  and  interest  in  the  welfare  of  its  children,  Cleveland  should 
not  discriminate  in  its  bounty.  All  children  of  school  age  should  receive 
equal  advantages  and  have  equal  opportunity  for  the  best  type  of 
health  care. 

5.  Children  of  whatever  age  who,  through  no  volition  on  their  part,  are 
deprived  of  home  care,  should  be  placed  in  other  homes  as  wards  of  the 
city,  or  should  be  given  proper  care  in  modern,  well-equipped  and  ade- 
quately maintained  day  nurseries  or  resident  institutions.  These  children 
are  entitled  to  the  same  kind  of  health  supervision  that  is  considered 
essential  for  all  children. 

6.  The  adolescent  child  is  entitled  to  adequate  protection  from  exploitation 
in  industry.     The  period  of  adolescence  is  one  of  extreme  importance 


270  Hospital  and  Health  Survey 


from  the  health  standpoint.  This  is  particularly  true  of  girls,  and  for 
individual  sound  health  and  future  welfare  of  the  race,  there  should  be 
stringent  regulations  from  the  health  point  of  view  for  the  protection 
of  all  children  during  this  hazardous  period  of  life. 

Proposed  Organization 

The  outstanding  need  for  effective  child-hygiene  work  in  Cleveland  at 
the  present  time  is  proper  organization  of  existing  facilities  of  public  and 
private  agencies  and  the  public  departments.  In  order  that  this  may  be 
made  effective,  there  must  be  (1)  central  control;    (2)  proper  coordination. 

At  the  present  time  the  community  as  a  whole  expresses  itself  in  health 
matters  through  the  Division  of  Health  and  through  the  health  control  of 
children  of  school  age  provided  by  the  Board  of  Education.  Even  within 
the  public  departments  there  is  divided  control,  but  among  the  private  and 
semi-public  agencies  this  division  is  more  sharply  marked.  It  is  neither 
necessary  nor  wise  for  private  agencies  to  sacrifice  their  individuality  in 
any  way  or  to  become  part  of  the  public  work  except  as  it  may  be  thought 
wise  from  time  to  time  for  the  public  to  assume  certain  types  of  child-hygiene 
effort  that  now  are  being  carried  on  by  private  associations.  It  is  essential, 
however,  that  there  should  be  some  coordinating  force  and  some  form  of 
central  organization  among  the  private  agencies  so  that  they  may  function 
completely  with  the  public  departments  in  the  most  effective  manner. 

/.  CENTRAL  CHILD  HYGIENE  COUNCIL 

As  part  of  the  general  health  organization  of  private  and  public  agencies, 
there  should  be  a  Central  Child  Hygiene  Council.  This  Council  should  have  a 
membership  consisting  of  a  representative  from  each  private  or  public  agency 
dealing  with  any  phase  of  child  health  supervision.  To  facilitate  administrative 
procedure,  such  a  council  should  be  divided  into  functional  groups,  each  having 
in  its  membership  one  person  representing  each  agency  in  its  class.  Each 
group  or  subdivision  should  elect  a  chairman,  such  chairmen  to  form  the  execu- 
tive committee  of  the  Central  Child  Hygiene  Council.  In  turn,  the  executive 
committee  should  elect  their  own  chairman  and  should  have  at  their  disposal 
a  paid,  full-time  executive  secretary  as  the  executive  officer  of  the  Section  on 
Child  Hygiene  of  the  proposed  Cleveland  Public  Health  Association. 

The  Central  Child  Hygiene  Council  should — 

/.  Coordinate  the  work  of  all  public  and  private  agencies,  promot- 
ing effective  cooperation  while  preserving  the  integrity  of  each 
unit. 

2.   Provide   for  an   equitable   distribution   of  functional  activity    to 
(a)    meet  existing  needs. 
(&)   prevent  duplication  of  effort. 


A  Program  for  Child  Health 


271 


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272  Hospital  and  Health  Survei 


(c)  attain   uniform   methods  of  procedure. 

(d)  extend  the  functions  to  cover  all  parts  of  the  city  and 
provide  the  needed  health  supervision  for  each  part. 

3.  Provide  for  each  type  of  child  hygiene  work  in  each  of  the  health 
zones*  or  districts  as  established  by  the  Division  of  Health. 

4.  Maintain  a  central  clearing  house  to 

(a)  receive  and  tabulate  all  essential  statistics  on  child 
welfare  work; 

(6)  act  as  intermediary  and  communicating  link  between 
the  functional  groups,  unless  (a)  is  provided  for  as 
suggested  in  the  chapter  on  "Vital  Statistics  within  the 
Division  of  Health."  (Part  II.) 

5.  Stimulate  public  opinion  to  obtain  adequate  appropriations 
for  child  health  work  under  the  Division  of  Health  and  the 
Board  of  Education. 

6.  Act  in  an  advisory  capacity  and  as  a  closely  cooperative  group 
to  the  city  government  to  promote  effective  public  health  work 
for  children. 

2.  PUBLIC  DEPARTMENTS 

The  Division  of  Health  and  the  Board  of  Education  should  provide  for  closer 
cooperation  with  each  other  and  with  the  private  child  hygiene  agencies.  This 
may  be  done  by — 

/.  The  appointment  by  the  respective  public  departments  of  a 
representative,  preferably  the  Director  of  the  Department  of 
School  Medical  Inspection  of  the  Board  of  Education  and  the 
Director  of  the  Bureau  of  Child  Hygiene  of  the  Division  of  Health, 
to  serve  as  a  cooperative  and  coordinating  committee  to  act 
on  all  matters  pertaining  to  child  health  which  concern  the  work 
of  both  departments,  such  as — 

(a)  Supervision  and  control  of  communicable  diseases  in 
children. 

(6)  Sanitation  and  hygiene  of  school  buildings  and  the 
homes  of  school  children. 

(c)    Supervision  of  the  health  of  children  of  pre-school  age. 

2.  The  appointment  by  these  departments  of  appropriate  represen- 
tatives to  serve  on  the  committees  of  the  Central  Child  Hygiene 
Council. 

The  above  type  of  organization  will  provide  for  strong  central  represen- 
tation from  the  Division  of  Health  and  the  Board  of  Education,  and  a  strong 

*  Throughout  this  report  the  term  "zone"  will  be  used  to  designate  that  division,  census  area  or 
health  district  that  may  be  decided  upon  as  the  unit  for  health  work.  These  zones  or  districts  should 
have  definite  boundaries,  which  may  comprise  one  or  more  sanitary  areas,  and  it  is  recommended  that 
such  zones  be  the  unit  for  all  health  work. 


A  Program  for  Child  Health  273 

central  body  representing  all  private  agencies,  with  the  machinery  so 
arranged  that  these  public  departments  and  private  agencies  shall  function 
harmoniously  and  without  waste  of  effort.  Such  a  type  of  organization  will 
not  only  provide  for  covering  the  territory  as  far  as  present  facilities  admit, 
but  also  will  call  attention  to  existing  needs,  provide  a  way  for  extension 
of  types  of  work  already  organized,  and  the  institution  of  new  kinds  of  work 
that  are  essential  for  continued,  well-rounded  child  care. 

Functional  Activities 

Prenatal  Care 
Present  Status  and  Needs: 

The  object  of  prenatal  care  in  Cleveland  should  be  to  provide  adequate 
instruction,  supervision  and  health  care  during  the  prenatal  period  for 
approximately  fifty  per  cent  of  all  pregnant  women,  estimated  at  ten 
thousand. 

About  thirty-five  per  cent  of  all  deaths  under  one  year  of  age  occur 
during  the  first  month  of  life.  Statistics  obtainable  from  many  cities  show 
that  this  death  rate  under  one  month  may  be  reduced  one-half  or  even 
two-thirds  by  proper  prenatal  supervision.  Provision  for  such  prenatal  care 
in  Cleveland  would  mean  that  from  three  hundred  to  four  hundred  baby 
lives  would  be  saved  each  year. 

Present  Provision  for  Prenatal  Care  in  Cleveland: 

During  1919,  2,848  prospective  mothers  received  prenatal  care  under 
the  auspices  of  four  institutions  through  nine  organized  centers.  This  work 
is  of  good  quality.  In  addition,  the  Visiting  Nurse  Association  and  a  number 
of  nurses  from  the  Division  of  Health  gave  prenatal  advice  to  all  pregnant 
women  with  whom  they  came  into  contact.  The  latter  service  undoubtedly 
gives  good  results,  but  it  would  seem  that  all  pregnant  women  should  have 
the  advantage  also  of  the  type  of  service  rendered  by  the  prenatal  clinics. 
In  addition  to  the  care  provided  for  2,848  mothers  in  1919,  it  is  evident 
that  Cleveland  should  make  provision  for  prenatal  care  for  at  least  seven 
thousand  more  prospective  mothers  annually. 

A  study  of  the  records  of  442  mothers  receiving  prenatal  care  in  the 
University  district,  where  the  baby  death  rate  was  found  to  be  much  higher 
than  the  rate  for  the  city  as  a  whole  showed  that,  even  under  such  circum- 
stances, it  was  possible  to  reduce  the  mortality  rate  among  babies  under  one 
month  of  age  to  24.8  per  thousand  births,  as  compared  with  the  city  rate 
of  31.4  per  thousand  births,  as  a  result  of  prenatal  care.  If  results  like  these 
can  be  obtained  in  a  district  where  the  racial,  social  and  economic  condi- 
tions are  such  as  to  result  ordinarily  in  an  unusually  high  baby  death  rate, 
it  is  quite  evident  that  far  better  results  might  be  expected  if  provision  for 
prenatal  care  could  be  extended  to  all  pregnant  women  of  the  city  who 
otherwise  would  be  without  such  supervision.    By  extending  this  service, 


274  Hospital  and  Health  Survey 

Cleveland  could  not  only  actually  save  from  three  hundred  to  four  hundred 
baby  lives  a  year  but  the  death  rate  among  mothers  from  accidents  and 
diseases  at  time  of  confinement  could  be  reduced  materially.  What  can  be 
accomplished  in  this  regard  may  be  seen  from  the  figures  given  out  by  the 
Maternity  Center  Association  of  New  York  City,  which  show  that  among 
502  women  supervised  during  their  pregnant  periods  and  receiving  proper 
care  at  time  of  confinement,  there  was  only  one  death.  Maternal  mortality 
Tanks  second  highest  in  the  list  of  causes  of  death  among  women  between 
fifteen  and  forty-five  years  of  age  in  the  United  States,  being  exceeded  only 
by  tuberculosis.  Reduction  in  the  death  rate  of  mothers  and  babies  as  a 
result  of  prenatal  care  can  be  effected  with  mathematical  certainty.  It  is 
simply  a  question  of  providing  the  type  of  care  that  has  already  been  recog- 
nized and  standardized. 

Reduction  of  the  still-birth  rate  in  the  University  District  from  28  per 
thousand  births  for  the  city  as  a  whole  to  20.4  per  thousand  births  among 
the  prenatal  cases,  and  reduction  in  the  death  rate  from  puerperal  sepsis 
from  four  per  thousand  births  for  the  city  as  a  whole  to  1.4  per  thousand 
births  for  the  cases  having  prenatal  care  also  warrants  favorable  comment. 
It  must  be  remembered,  however,  that  this  reduction  applies  only  to  a 
limited  group  of  pregnant  women,  i.  e.,  2,848  of  a  total  of  19,123  registered 
births  in  1919.  It  shows  what  may  be  done  and  makes  it  clearly  evident 
that  Cleveland  needs  three  times  the  facilities  for  prenatal  care  that  she 
has^at  present. 

RECOMMEND  A  TIONS 

1.  It  seems  evident  that  the  Division  of  Health  cannot  at  present  secure  the  neces- 
sary funds  to  carry  on  a  city-wide  service  in  prenatal  care.  Ultimately,  this  work 
should  be  one  of  the  functions  of  the  Bureau  of  Child  Hygiene,  paid  for  by  ap- 
propriation of  city  funds.  Until  this  can  be  accomplished,  however,  the  respon- 
sibility must  rest  upon  private  initiative  and  should  be  carried  on  by  private 
agencies. 

2.  It  is  suggested  that  a  Committee  on  Prenatal  Care  of  the  Central  Child 
Hygiene  Council  be  composed  as  follows: 

(a)  An  obstetrician  or  other  representative  from  each  hospital  or 
other  institution  having  an  obstetrical  service  under  the  direc- 
tion of  a  specialist  in  obstetrics,  either  in  the  hospital  or  at  the 
patient's  home. 

(b)  A  member  of  the  Academy,  Committee  on  Public  Health.' 

(c)  A  representative  of  the  nursing  staffs  of  the  University  District 
and  the  Visiting  Nurse  Association. 

(<f)  A  representative  of  the  Division  of  Health. 

3.  Facilities  for  prenatal  care  are  offered  in  Cleveland  by  four  institutions — 
the  Maternity  Hospital  Dispensary,  through  its  six  clinics;  the  University  District 
Dispensary;  St.  Lube's  Hospital  Dispensary  and  Mt.  Sinai  Hospital  Dispensary. 
These  hospitals  and  the  home  nursing  services  of  the  Visiting  Nurse  Association 
and  the  Division  of  Health  should  hold  themselves  responsible  for  maintaining 


A  Program  for  Child  Health  275 


and  providing  proper  professional  services  at  the  maternity  centers  in  each  of 
the  specified  zones  of  the  city.  Each  zone  should  have  one  or  more  centers,  in 
accordance  with  its  needs.  The  service  should  be  free,  except  where  the  eco- 
nomic status  of  any  locality  may  warrant  the  establishment  of  a  center  where  a 
moderate  fee  may  be  charged. 

4.  No  institution  should  take  patients  from  any  zone  not  under  its  con- 
trol, except  by  reference  from  another  institution,  at  the  special  request  of  the 
patient  concerned,  or  as  a  matter  of  professional  courtesy  between  the  directors 
of  the  respective  services. 

5.  Expectant  mothers  should  be  encouraged  to  attend  the  maternity  cen- 
ters in  their  zones,  and  should  be  referred  there  by 

(a)    Visiting  nurses. 

(6)  Division  of  Health  nurses. 

(c)   Social  workers. 

(</)  Hospitals. 

(e)  Physicians. 

(f)  Midwives. 

(g)  Any  other  persons  who  may  have  knowledge  of  such  cases. 

6.  All  cases  of  delivery  should  be  sent  to  the  physician  or  midwife  referring  the 
patient  to  the  prenatal  clinic,  or  to  the  hospital  responsible  for  the  zone  in  which  the 
patient  lives. 

7.  There  should  be  submission  at  specified  intervals  to  the  executive  secretary  of 
the  Central  Child  Hygiene  Council  of 

(a)  Full  reports  of  all  statistical  data  of  work  performed  and  results  obtained. 

(b)  All  complaints  of  discrimination  in  favor  of  or  against  any  institution  or 
individual,  and  matters  requiring  adjustment  of  policy. 

8.  The  Committee  on  Prenatal  Care  should  prepare 

(a)  Standard  forms  for  recording  all  essential  data. 

(b)  Standard  methods  of  prenatal  care. 

These  forms  and  methods  should  be  adhered  to  by  each  clinic. 

9.  Provision  should  be  made  for  necessary  home  visits  by  nurses  who  are  directly 
assigned  to  duty  at  the  prenatal  clinic  or  by  the  Visiting  Nurse  Association 

Maternity  Care 

Present  Status  and  Needs: 

I.  Present  Hospital  Facilities: 

There  are  seventeen  hospitals  in  Cleveland  which  have  set  aside  a  total 
of  three  hundred  and  fifteen  beds  for-  maternity  cases.  The  total  number 
of  institutional  deliveries  in  1919  was  4,980.  The  number  of  institutional 
deliveries  has  increased  from  11.5%  of  the  total  births  registered  in  1915 


276  Hospital,  and  Health  Survey 

to  26°^  in  1919.  Two  agencies — the  Maternity  Hospital  and  St.  Luke's — 
gave  out-patient  service  for  maternity  cases,  the  Maternity  Hospital  deliver- 
ing in  1919,  1,156  patients,  and  St.  Luke's,  101.  The  Visiting  Nurse 
Association  gave  nursing  service  to  234  confinement  cases. 

2.  Birth  Registration: 

The  registration  of  births  in  Cleveland  is  inadequate.  A  number  of 
births  were  taken  from  the  city  at  large  and  checked  at  the  Bureau  of  Vital 
Statistics  x>f  the  Division  of  Health  to  see  how  many  had  been  registered. 
The  following  results  were  obtained: 


Total  for 

1918 

1919 

1920 

1918-19-20 

128 

429 

57 

614 

82 

267 

34 

383 

Total  for 

1919 

1920 

1918-19-20 

451 

77 

669 

362 

46 

522 

Total  number  of  birth  records  investigated.. 

Total  number  found  registered.... 

Percentage    of    birth    records    investigated 

found  registered 64%  62%  59.5%  62% 

These  results,  with  55  additional,  were  checked  over  carefully,  looking 
under  every  possible  date  and  spelling.  As  a  result  of  this  re-investigation, 
the  following  results  were  obtained: 


1918 
Total  number  of  birth  records  investigated...        141 

Total  number  found  registered 104 

Percentage     of    birth    records    investigated 

found  registered 74%      '      80.2%  59%  78% 

In  addition,  a  list  of  baptisms  from  various  churches  of  the  city  were 
looked  up,  with  the  following  results: 

Pilgrim  Trinity  St.  Paul's  2d  Presb.  Total 

Total  number  of  birth  records  in- 
vestigated           25  28  11  3                67 

Total  number  found  registered... 22  24  8  3                57 

Percentage  of  birth  records  investi- 
gated found  registered 88%  86%  73%  100%  85% 

These  investigations  would  seem  to  show  that  not  over  eighty  per  cent 
of  the  births  occurring  in  Cleveland  are  reported  to  and  registered  by  the 
Bureau  of  Vital  Statistics  of  the  Division  of  Health.  Xo  action  is  being 
taken  by  the  Division  of  Health  against  persons  who  fail  to  report  births, 
nor  is  there  any  evidence  that  proper  measures  are  being  taken  to  check 
up  birth  registration.  A  beginning  has  been  made  toward  requiring  a  birth 
certificate  as  evidence  of  age  for  school  enrollment.  Failure  to  report  births 
seems  to  be  common  both  to  physicians  and  midwives.  Analysis  was  made 
of  one  hundred  deaths  under  two  years  of  age,  which  showed  that  physi- 


A  Program  for  Child  Health  277 


cians  had  failed  to  report  39.2%  of  the  births  which  had  occurred  under 
their  supervision,  and  midwives  had  failed  to  report  47%  of  the  births 
attended  by  them. 

3.  Midwives: 

It  is  estimated  that  there  are  one  hundred  and  sixty  licensed  and  one 
hundred  and  ten  unlicensed  midwives  in  Cleveland.  It  is  evident  that  the 
regulations  of  the  State  Medical  Board  of  Ohio  are  such  that  midwives  are 
practically  barred  from  obtaining  licenses  in  Cleveland  at  the  present  time. 
During  1919-1920  only  two  midwives  received  licenses  to  practise.  The 
type  of  supervision  given  to  midwives  who  are  practising  is  inadequate, 
amounting  to  an  average  of  less  than  one  call  a  year  upon  each  midwife 
during  1919.  It  is  evident,  also,  that  midwives  are  allowed  to  practise 
without  being  licensed. 

4-.  Relative  Number  of  Births  Reported  by  Midwives  and  by  Physicians: 

During  the  past  five  years,  of  the  total  number  of  registered  births, 
from  55.5%  in  1913-14  to  65%  in  1918-19,  were  reported  by  physicians, 
and  from  44.5%  in  1913-14  to  33.9%  in  1918-19  were  reported  by  mid- 
wives.  From  this  it  is  apparent  that,  while  the  practice  of  midwives  is 
decreasing,  it  still  is  of  sufficient  extent  to  warrant  attention,  serving  as  it 
did  in  1919,  5,903  pregnant  women.  It  is  evident  that,  notwithstanding 
the  extensive  hospital  and  out-patient  maternity  services,  there  is  a  large 
proportion  of  women  in  Cleveland  who  prefer  the  services  of  midwives  at 
the  time  of  confinement.  This  experience  is  common  in  all  cities  having  a 
large  alien  population.  The  great  majority  of  these  women  accept  the 
midwife  in  the  traditional  manner.  Neither  they  nor  their  families  have 
ever  known  any  other  type  of  attendant  at  birth.  In  addition,  among 
certain  foreign  groups,  the  husbands  of  the  women  are  prejudiced  against 
having  men  in  attendance  at  the  time  of  confinement.  There  can  be  no 
doubt  that,  from  the  point  of  view  of  the  patient,  the  midwife  fills  a  social 
need.  There  is  no  evidence  to  show  that  midwives  can  be  eliminated  by 
outlining  regulations  of  so  stringent  a  character,  as  a  requisite  for  a  license 
to  practise  midwifery,  that  no  midwife  can  possibly  comply  with  them.  There 
is,  furthermore,  a  serious  inconsistency  in  any  type  of  administration  which 
allows  unlicensed  and  untrained  midwives  to  practise,  but  refuses  to  recog- 
nize the  graduates  of  such  schools  as  that  maintained  by  the  City  of  New 
York,  or  graduates  of  the  high  types  of  schools  that  are  maintained  in  Eng- 
land. In  fact,  the  regulations  now  in  force  in  the  City  of  Cleveland  would 
bar  not  only  graduates  of  the  best  schools  in  this  country  but  those  of  the 
great  majority  of  the  European  schools.  The  regular  course  in  midwifery 
schools  in  England  covers  a  period  of  six  months,  in  New  York  City  eight 
months,  while  on  the  Continent  the  average  course  is  from  twelve  to  eighteen 
months.  To  require  a  two  years'  course  in  midwifery,  therefore,  is  pro- 
hibitive.    It  is  appalling  to  think  of  the  results  of  a  system  of  midwifery 


L278  Hospital  and  Health  Survey 


control  which,  by  its  inherent  qualities,  systematically  ignores  the  dangerous 
results  that  may  come  from  allowing  ignorant,  untrained  women  to  prac- 
tise midwifery  without  supervision  or  instruction. 

5.  Prevention  of  Blindness: 

Excellent  results  have  been  obtained  from  the  follow-up  of  cases  of 
ophthalmia  neonatorum.  It  is  stated  that  only  one  case  of  blindness  due 
to  gonococcal  infection  has  occurred  among  children  born  in  Cleveland 
during  the  past  five  years. 

RECOMMEND  A  TIONS 

1.  Committee  Formation: 

In  order  to  provide  for  the  right  distribution  of  the  present  hospital  facili- 
ties for  maternity  care  throughout  the  city,  there  should  be  an  Obstetrical  Coun- 
cil or  a  Committee  on  Maternity  Care  of  the  Central  Child  Hygiene  Council, 
such  committee  to  consist  of 

(a)   An  obstetrician  or  other  representative  from  each  of  the   mater- 
nity hospitals. 
(6)  A  representative  of  the  Bureau  of  Child  Hygiene  of  the  Division 

of  Health. 
(c)   A  representative  of  the  Visiting  Nurse  Association. 
The  functions  of  this  committee  might  well  be  served  by  the  committee  on  prenatal 
care  as  outlined  above,  page  274. 

2.  Birth  Registration: 

(a)  Adequate  birth  registration  is  absolutely  essential  as  a  basis  for  effective  child 
hygiene  work.  It  is  essential  to  know  how  many  babies  are  born,  their  race,  sex  and 
residence.  The  Division  of  Health  should  take  whatever  steps  may  be  necessary 
to  give  Cleveland  as  nearly  one  hundred  per  cent  birth  registration  as  is  humanly 
possible.      This  may  be  done  by 

1 .  Investigating  deaths  of  babies  under  six  months  of  age  to  deter- 
mine whether  the  births  were  registered. 

2.  Receiving  reports  of  names,  addresses,  dates  and  places  of  birth 
of  all  babies  registered  at  the  health  centers  and  investigating 
same  with  reference  to  birth  registration. 

3.  Returning  a  copy  of  the  birth  certificate  to  the  mother  of  each 
baby  whose  birth  is  recorded. 

4.  Prosecuting  all  physicians,  midwives  and  others  who  fail  to  report 
births  as  required  by  law. 

(6)  In  order  to  make  the  statistics  of  births  available  as  a  basis  of  work, 
facilities  should  be  afforded  for  analysis  of  these  records,  by  zones,  so  that  any 
information  regarding  distribution  or  other  questions  connected  with  the  birth 
rate  may  be  available  immediately  to  persons  interested  in  child  welfare  work. 
For  further  details  see  chapter  on  Vital  Statistics,  Part  II. 


A  Program  for  Child  Health  279 

3.  Hospital  Facilities: 

The  present  provision  for  beds  for  maternity  cases  seems  adequate,  and  when  the 
out-patient  maternity  services  also  are  considered,  it  is  deemed  inadvisable  to  recommend 
any  extension  of  free  maternity  bed  service  at  the  present  time.  There  are,  however, 
methods  which  might  be  employed  to  make  this  service  a  more  integral  part  of  the  child 
health  program.     These  are  that 

(a)  Each  hospital  providing  maternity  service  should  assume  respon- 
sibility for  certain  zones  and  for  the  care  of  all  women  needing 
and  desiring  free  obstetrical  care  who  reside  in  such  zones.  It 
should  be  agreed  that  patients  residing  in  other  zones  will  not  be 
taken  by  any  hospital  other  than  that  responsible  for  the  zone 
in  question,  unless  by  special  arrangement  in  each  case  with 
the  hospital  or  institution  in  charge  of  the  zone  in  which  the 
patient  resides. 

(b)  All  patients  who  register  in  advance  should  be  referred  to  the 
prenatal  clinics  for  proper  supervision. 

(c)  Standard  forms  of  record-keeping  and  compilation  of  statistics 
as  outlined  by  the  Committee  on  Maternity  Care  should  be 
used. 

(d)  All  mothers  after  confinement  should  be  referred  to  the  health 
centers.  This  can  be  done  by  using  a  duplicate  card,  one  sec- 
tion to  be  given  to  the  mother,  referring  her  to  the  health  center 
or  prophylactic  baby  health  station  in  the  zone  in  which  she 
lives,  the  other  to  be  sent  to  the  executive  secretary  of  the  Cen- 
tral Child  Hygiene  Council,  who  will  refer  it  to  the  indicated 
health  center.  If  the  mother  does  not  appear  at  the  center 
within  twenty-four  hours,  a  nurse  should  visit  her  at  her  home  to 
induce  her  to  register.  Whenever  a  mother  is  referred  to  a 
health  center,  the  essential  points  in  the  history  of  the  case 
and  the  feeding  and  care  of  the  baby  should  be  forwarded  by  the 
hospital  or  other  institution  to  the  health  center. 

(e)  Extension  of  the  out-patient  service  in  zones  where  the  hos- 
pital facilities  are  inadequate. 

(f)  Extension  of  the  work  of  the  Visiting  Nurse  Association  to  give 
proper  obstetrical  nursing  for  the  out-patient  service  in  all  zones. 

4.  Suggested  Program  for  the  Control  of  Midwifery: 

(a)  Regulations  for  the  control  of  midwifery  should  be  amended 
so  that  the  graduates  of  reputable  midwifery  schools  of  recog- 


'iSO  Hospital  and  Health  Survet 

nized  standard,  which  maintain  courses  of  not  less  than  six 
months'  duration,  may  be  admitted  to  practise,  after  passing 
the  necessary  state  examinations.  All  midwives  who  are  unable 
to  qualify  under  such  a  system  of  regulation  should  be  denied 
the  right  to  practise,  and  should  be  prosecuted  if  they  attempt  to. 

(6)  The  present  midwifery  law  should  be  amended  so  that  it  will 
not  be  retroactive  from  the  date  of  its  first  enforcement.  Mid- 
wives  who  were  already  practising  when  the  law  became  effective 
should  be  granted  licenses  to  continue,  by  virtue  of  their  having 
practised  before.  Reasonable  and  adequate  but  not  unattain- 
able standards  should  be  drawn  up  for  midwives  who,  in  future, 
may  apply  for  permits  to  practise.  The  rules  and  regulations 
governing  the  practice  of  midwifery  should  be  enforced  rigor- 
ously, and  any  midwife  who  is  found  not  to  have  complied  with 
such  rules  and  regulations  should  be  prosecuted.  If  found 
guilty,  her  license  should  be  revoked.  By  this  method  a  gradual 
elimination  of  unfit  midwives  can  be  accomplished  in  a  manner 
that  will  protect  the  interests  of  the  community  and  of  the 
mothers,  and  at  the  same  time  solve  the  problem  of  the  present 
incongruous  situation  in  Cleveland,  whereby  unlicensed  mid- 
wives  are  permitted  to  practise  but  are  not  kept  under  proper 
supervision. 

(c)  A  system  of  supervision  should  be  inaugurated  at  once,  under 
the  Division  of  Health,  Bureau  of  Child  Hygiene,  whereby  as 
part  of  the  work  of  the  health  centers  midwives  will  be  kept 
under  constant  and  continuous  supervision.  They  should  be 
encouraged  to  improve  the  methods  of  their  practice,  should 
be  taught  how  to  attain  a  safe,  decent  technic  and,  as  far  as 
possible,  the  actual  type  of  work  performed  by  them  should 
be  known  by  having  nurses  attend  cases  with  them  and  keep 
them,  under  constant  supervision.  Midwives  should  be  required 
to  keep  records  of  all  cases  attended  by  them  and  should  be  held 
strictly  accountable  for  adherence  to  the  rules.  The  rules  and 
regulations  governing  the  practice  of  midwifery  in  New  York 
City  and  in  New  York  State  will  serve  as  useful  examples  of 
practical  measures  which  can  be  and  are  being  enforced. 

Infant  Care 
Present  Status  and  Needs: 

Infant  care  in  Cleveland  is  carried  on  under  the  control  of  the  Bureau 
of  Child  Hygiene  of  the  Division  of  Health,  through  fourteen  health  centers. 
In  eight  of  these  centers  work  for  the  control  of  tuberculosis,  supervision 


A  Program  for  Child  Health  281 


of  contagious  diseases,  including  eye  conditions  and  nursing  inspection  of 
children  of  the  parochial  schools,  also  are  provided  for.  In  two  of  the  centers 
venereal  disease  work  also  is  carried  on. 

1.  It  is  estimated  that  there  are  in  Cleveland  at  least  twenty  thousand 
children  under  two  years  of  age  who  should  have  the  type  of  health  super- 
vision which  their  parents  are  unable  to  obtain  for  them  without  community 
help. 

2.  The  health  centers  are  well  distributed  throughout  the  city  but,  owing 
to  the  widely  scattered  population  in  certain  areas  and  consequent  dis- 
tances to  be  traveled  by  the  mothers,  they  do  not  cover  the  field  of  needed 
infant  care. 

3.  The  medical  work  in  these  health  centers  is  of  the  five  types  enu- 
merated above.  It  is  controlled  by  the  heads  of  three  bureaus  of  the  Division 
of  Health — the  Bureau  of  Tuberculosis,  the  Bureau  of  Communicable  Dis- 
eases, and  the  Bureau  of  Child  Hygiene.  *The  nurses  in  the  health  centers 
carry  on  what  is  known  as  "generalized"  nursing;  that  is,  they  divide  their 
time  among  all  the  functions  that  are  served  by  the  centers.  From  the 
point  of  view  of  the  efficiency  of  the  infant  welfare  service,  this  type  of 
nursing  would  seem  to  be  unfortunate.  The  proportion  of  time  given  to 
infant  care  at  the  centers  is  wholly  inadequate. 

4.  Administrative  work  and  office  duties  by  the  nurses  occupy  too  great 
a  proportion  of  their  time.  On  a  basis  of  one  hundred  hours  of  service  for 
the  nurses  at  the  health  centers,  41.9%  of  this  time  was  found  to  be  devoted 
to  office  duties.  This  disproportion  of  service  works  to  the  detriment  of  the 
regular  nursing  functions,  and  may  account  in  great  measure  for  the  neglect 
of  the  proper  follow-up  work  among  babies. 

5.  Not  enough  nurses  are  assigned  to  duty  at  each  center  to  care  ade- 
quately for  the  functions  placed  under  their  supervision.  Each  nurse  has 
too  many  patients  under  her  care.  Reference  to  the  chapter  on  Nursing 
Service,  Part  IX,  will  show  that  each  nurse  has  approximately  three  hundred 
cases  to  care  for,  including  two  hundred  babies.  This  is  greatly  in  excess  of 
the  maximum  that  can  be  supervised  effectively.  A  study  of  the  records 
at  the  Health  Centers  shows  that  an  average  of  .4  visits  is  paid  each  baby 
each  month;  that  is,  each  baby  is  visited  about  once  in  every  two  to  two 
and  a  half  months.  One  in  every  nine  babies  comes  to  the  clinic  once  during 
the  month.  It  is  evident  from  a  study  of  individual  record  cards  and  of 
the  various  reports  on  nursing  service  in  this  Survey  that  home  visits  to 
babies  are  neglected,  that  there  is  little  attempt  to  check  up  regularity 
of  attendance,  to  give  proper  and  necessary  home  supervision,  or  to  see  that 
delinquent  cases  are  brought  back  to  the  centers.  It  is  evident  that  too 
great  reliance  is  placed  upon  distribution  of  milk  as  a  bait  to  draw  mothers 
to  the  centers.  While  this  may  account  in  great  measure  for  the  fairly  ade- 
quate attendance,  it  in  no  way  compensates  for  the  loss  that  is  apparent 
in  the  lack  of  proper  teaching  of  hygiene  in  the  home  and  supervision 
of  the  baby's  environment. 

*  The  information  concerning  the  scope,  character,  excellencies  and  defects  of  the  nursing  service- 
in  the  Division  of  Health  and  the  schools,  used  in  this  report,  was  obtained  from  the  reports  of  the  investi- 
gators who  collaborated  under  Miss  Josephine  Goldmark's  direction  in  the  preparation  of  the  chapter  on 
Nursing  Service  in  Cleveland,  Part  IX. 


Hospital  and  Health  Survey 


6.  There  is  no  organized  method  of  referring  cases  to  the  health  centers. 
Outgoing  mothers  and  babies  from  maternity  hospitals  are  not  referred  to 
the  centers,  and  there  is  no  apparent  recognition  of  the  value  of  enlisting 
the  cooperation  of  midwives  in  referring  babies  born  under  their  care,  a 
type  of  case  which  is  particularly  in  need  of  such  supervision. 

7.  Infant  feeding  by  artificial  means  has  been  developed  to  a  high 
standard  of  efficiency,  but  statistical  evidence  would  seem  to  show  that  too 
great  emphasis  is  placed  on  methods  of  artificial  or  substitute  feeding,  with 
consequent  apparent  neglect  of  the  importance  of  breast  feeding.  Three 
separate  studies  which  were  made  of  babies  under  the  care  of  the  health 
centers,  show  that  the  number  of  babies  breast  fed  varied  from  29  to  60 
per  cent.  There  is  indisputable  evidence  available  to  the  effect  that  ninety- 
five  per  cent  of  all  women  can  nurse  their  babies.  As  a  measure  for  the 
reduction  of  infant  mortality,  encouragement  of  breast  feeding  is  probably 
of  greater  importance  than  most  highly  developed  methods  of  substitute 
feeding. 

8.  While  specific  criticism  of  the  many  and  varied  types  of  work  required 
of  the  nurses  may  not  be  advisable,  in  view  of  the  determined  policy  to 
carry  on  generalized  nursing  service,  there  is  evidence  that  infant  hygiene 
work,  both  at  the  health  centers  and  in  the  homes,  is  neglected.  The  nursing 
reports  show  that  home  visits  are  too  infrequent  and  irregular,  and  from  the 
records  it  appears  that  nursing  care  (to  infants)  is  rarely  given,  and  then 
very  inadequately.  Owing  to  the  many  duties  which  the  nurse  is  called 
upon  to  assume  and  the  large  number  of  patients  under  her  control,  follow- 
up  visits  to  babies  in  their  homes,  and  the  supervision  necessary  to  see  that 
the  babies  are  brought  to  the  clinics  regularly,  have  been  so  far  neglected 
that  in  a  considerable  proportion  of  instances  it  was  found  that  the  babies 
had  not  been  seen  for  periods  of  from  two  to  three  months,  and  that  there 
was  no  record  as  to  what  had  become  of  them  during  that  time.  Such 
neglect  leads  to  the  inference  that  preventive  health  work  for  infants  has 
been  relegated  to  a  place  of  minor  importance.  Such  a  result  may  reason- 
ably be  expected  when  the  nurses  are  required  to  attend  to  so  many  kinds 
of  work  which,  by  their  very  nature,  are  of  more  emergent  type.  It  is  quite 
natural  that  in  any  combined  medical  or  nursing  work  the  corrective  or 
emergent  cases  will  be  given  precedence.  Without  underrating  the  impor- 
tance of  contagious  disease  and  tuberculosis  supervision,  venereal  disease 
control  or  school  inspection,  attention  may  well  be  called  to  the  inequality 
of  the  prophylactic  work  for  babies  which,  by  its  nature,  is  non-emergent 
in  character,  but  which  is  of  the  utmost  importance  in  any  effective  public 
health  program  which  has  for  its  object  a  reduction  of  infant  sickness  and 
death. 

While  medical  advice  can  be  given  in  an  adequate  manner  at  the  health 
centers,  the  value  of  the  nurses'  work  is  more  clearly  shown  in  their  home 
visits.  Only  in  that  way  can  they  be  sure  that  the  proper  routine  is  being- 
carried  out,  that  the  directions  of  the  doctor  are  being  obeyed  and  that  the 
mother  not  only  understands  but  actually  puts  into  effect  the  essential 
methods  of  babv  care.    The  baby's  immediate  environment  is  its  mother, 


A  Program  for  Child  Health  283 

but  its  home  surroundings  are  only  slightly  less  remote  in  degree,  con- 
sequently the  many  factors  of  hygiene  and  sanitation  which  have  so  direct 
an  effect  upon  the  lives  of  infants  can  be  adjusted  and  controlled  only  if 
the  nurses  make  systematic  and  regular  home  visits.  If  the  administrative 
experiment  in  so-called  "generalized"  public  health  nursing  is  to  be  con- 
tinued, as  for  some  reasons  appears  desirable,  radical  change  in  the  organiza- 
tion, distribution  and  supervision  of  the  nurses'  work  must  be  undertaken 
promptly. 

9.  There  is  no  agency  in  Cleveland  for  supplying  wet  nurses.  The  use 
of  wet  nurses  is  recognized  as  an  important  factor  in  saving  the  lives  of 
young  babies.  Breast  feeding  plays  such  an  important  part  in  the  pre- 
vention of  infant  sickness  and  death  that  provision  for  some  opportunity 
for  obtaining  the  services  of  wet  nurses  is  a  recognized  part  of  the  community 
program  for  the  reduction  of  infant  morbidity  and  mortality. 

RECOMMENDA  TIONS 

1.  A  Committee  on  Infant  Care  should  be  formed  as  part  of  the  Central 
Child  Hygiene  Council.      This  committee  should  consist  of 

(a)  A  representative  from  the  Bureau  of  Child  Hygiene  of  the  Divi- 
sion of  Health. 

(6)  A  representative  of  the  Visiting  Nurse  Association. 

(c)  A  representative  of  the  Babies'  Dispensary. 

(d)  A    representative    of    the    hospitals    providing   special   maternity 
services. 

(e)  A  representative  of  the  Committee  on  Prenatal  Care. 

2.  The  Division  of  Health  should  extend  its  health  centers,  particularly  those 
devoted  wholly  to  preventive  health  work  for  infants.  If  it  is  not  possible  at  the 
present  time  to  establish  more  of  these  health  centers,  the  minimum  require- 
ment should  be  at  least  one  center  in  each  zone,  with  sufficient  nurses  attached 
so  that  home  visits  may  be  made  to  the  families  of  all  infants  who  need  such 
attention  and  who  live  at  too  great  distances  from  the  centers  to  attend  regu- 
larly. 

3.  Each  center  should  be  furnished  each  day  with  a  list  of  names  and  ad- 
dresses of  all  babies  whose  births  were  reported  from  the  indicated  zone  on  the 
previous  day.  Each  such  case  should  be  visited  and  the  mother  urged  to  attend 
the  center.  If  she  is  unable  to  do  this,  she  should  be  kept  under  observation  by 
the  visiting  nurse. 

4.  The  personnel  of  the  staff  at  each  health  center  should  be  increased. 
With  the  present  distribution  and  types  of  work,  each  nurse  should  have  under 
her  supervision  not  more  than  one  hundred  cases.      If  it  is  impossible  to  increase 


284  Hospital  and  Health  Survey 


the  staff  at  the  present  time,  attention  should  be  directed  immediately  toward 
relieving  the  nurses  of  the  greater  part  of  their  office  duties.  Clerks  should  be 
employed  for  this  purpose,  and  the  nurses  should  devote  their  entire  time  to 
nursing  work. 

5.  It  is  essential  for  effective  work  that  the  number  of  home  visits  to  babies 
should  be  increased  and  that  these  home  visits  should  be  carried  out  with  reg- 
ularity. 

6.  More  emphasis  should  be  placed  upon  the  general  education  of  the  mother 
in  methods  of  proper  baby  care,  in  addition  to  the  question  of  feeding. 

7.  Increased  attention  should  be  paid  to  the  necessity  for  breast  feeding. 
Methods  of  restoring  lactation  and  encouraging  mothers  to  continue  to  nurse 
their  infants  should  be  insisted  upon  more  vigorously  than  they  are  at  the  present 
time.  Every  effort  should  be  made  to  increase  the  relative  proportion  of  breast 
feeding  among  infants  in  attendance  at  the  health  centers. 

8.  Efforts  should  be  made  through  the  committees  of  the  Central  Child 
Hygiene  Council  to  obtain  effective  cooperation  from  other  agencies.  Coopera- 
tion should  be  maintained  with  the  prenatal  clinics  and  maternity  hospitals  in 
obtaining  histories  of  all  cases  cared  for  by  them  who  afterward  are  referred  to 
the  baby  clinics  of  the  health  centers. 

9.  Babies  should  not  be  discharged  from  control  of  the  health  centers  when 
they  reach  the  age  of  two  years. 

10.  Health  centers  should  extend  their  functions  to  include  care  of  the 
child  of  preschool  age.  For  discussion  of  this  question,  reference  is  made  to 
the  discussion  of  "Preschool  age  Care,"  which  follows. 

11.  There  should  be  established  at  each  health  center  a  wet  nurse  registry. 
This  should  be  maintained  in  cooperation  with  the  Committee  on  Maternity  care  of 
the  Central  Child  Hygiene  Council.  Effort  should  be  made  also  to  obtain  the 
cooperation  of  midwives  in  this  regard.  Mothers  whose  babies  have  died  should 
be  asked  to  register  as  wet  nurses.  Each  woman  so  registered  should  receive  a 
thorough  physical  examination,  including  a  Wassermann  test.  The  facilities  of 
this  wet  nurse  registry  should  be  open  to  all  physicians  of  the  city. 

Pre-School  Age  Care 
Present  Status  and  Needs: 

1.  Statistics  of  the  United  States  Census  Bureau  show  that  eighty  per 
cent  of  all  deaths  from  contagious  diseases  occur  under  five  years  of  age. 
Less  reliable  morbidity  statistics  would  seem  to  indicate  that  from  eighty- 
five  to  ninety  per  cent  of  all  cases  of  contagious  diseases  occur  in  children 


A  Program  for  Child  Health  285 


under  five  years  of  age.  Examination  of  children  of  this  age  group  has  re- 
vealed the  presence  of  physical  defects  in  greater  proportion  than  in  the 
ten  to  fifteen-year-age  group.  Studies  of  the  relative  occurrence  of  physical 
defects  show  that  practically  all  of  them  can  be  prevented  or  at  least  cor- 
rected in  their  early  stages  during  the  pre-school  age  period. 

2.  Facilities  for  the  health  supervision  of  children  of  pre-school  age  in 
Cleveland  are  almost  wholly  lacking.  There  are  seven  day  nurseries  in 
Cleveland,  five  of  which — the  Mather,  Louise,  Lend-a-hand,  Perkins  and 
Wade — are  branches  of  the  Cleveland  Day  Nursery  and  Free  Kindergarten 
Association.  One — Merrick  House — is  conducted  in  connection  with  that 
settlement  house,  and  the  other — Joseph  &  Feiss — by  that  industrial  plant 
for  the  children  of  its  employes.  The  aggregate  service  provided  by  these 
day  nurseries  in  1919  was  47,085  child  days,  and  the  daily  average  attend- 
ance was  184.75  children.  It  may  thus  be  seen  that  the  day  nurseries  of 
Cleveland  are  caring  for  less  than  two  hundred  children  daily  out  of  an 
estimated  child  population  of  sixty  thousand  between  two  and  five  years 
of  age. 

3.  It  is  estimated  that  fifty  per  cent  of  the  children  between  two  and 
five  years  of  age,  a  total  of  thirty  thousand,  are  probably  without  any  health 
supervision. 

4.  This  neglect  of  supervision  of  the  child  of  pre-school  age  is  the  greatest 
gap  in  the  continuity  of  Cleveland's  child-health  program.  The  importance 
of  caring  for  this  age-group  cannot  be  overestimated. 

RECOMMEND  A  TIONS 

Immediate  steps  should  be  taken  to  provide  the  necessary  facilities  for  health 
supervision  of  children  of  pre-school  age.  It  is  recommended  that  this  be  done 
through  the  health  centers  as  a  continuation  of  the  work  of  infant  care.     It  is 

realized  that  the  pre-school  age  bears  a  very  intimate  relation  not  only  to  the  period  of 
infancy  but  also  to  the  period  of  school  life.  It  may  well  be  considered,  therefore,  whether  the 
school  should  be  responsible  for  the  care  of  the  pre-school  age  child,  or  whether  this  should 
be  considered  simply  an  extension  of  the  period  of  infancy.  Logically,  the  school  should 
consider  that  the  pre-school  age  bears  the  same  relation  to  the  school  age  as  the  prenatal 
period  bears  to  infancy,  and,  theoretically,  it  should  be  the  duty  of  the  school  authorities 
to  see  that  children  of  pre-school  age  are  so  cared  for  and  their  health  so  supervised  that 
they  will  be  in  sound  physical  condition  when  they  enter  school.  From  a  practical  view- 
point, however,  such  a  course  seems  inexpedient  at  the  present  time.  It  is  probable  that 
money  appropriated  for  school  purposes  could  not  be  used  for  the  benefit  of  children  who 
have  not  yet  reached  the  legal  school  age.  While  it  is  possible,  of  course,  that  private 
funds  to  establish  clinics  for  children  of  pre-school  age  in  connection  with  the  service  of 
school  medical  inspection  in  the  public  and  parochial  schools  may  be  obtained,  it  seems 
at  the  present  time  that  the  need  would  be  most  completely  served  by  considering  the 
supervision  of  children  of  pre-school  age  one  of  the  functions  of  the  health  centers,  under 
the  Division  of  Health. 


"286  Hospital  and  Health  Survey 


Such  service  should  be  carried  on  as  follows: 

1.  Children  who,  as  infants,  have  been  under  the  care  of  the  health 
centers,  up  to  two  years  of  age,  should  not  be  discharged  from 
observation  at  the  end  of  that  time  but  should  be  continued  on 
register  as  preschool  age  cases. 

2.  The  personnel  of  the  health  centers  should  be  increased  to  pro- 
vide sufficient  doctors  and  nurses  to  give  the  necessary  supervision 
to  children  of  pre-school  age. 

3.  Close  cooperation  should  be  maintained  with  hospitals,  day  nur- 
series, the  Board  of  Education,  social  service  agencies  and  other 
sources  so  that  children  between  two  and  five  years  of  age  may  be 
referred  to  the  health  centers  for  health  supervision. 

4.  Each  child  of  pre-school  age  should  receive  a  physical  examination 
at  least  once  every  six  months  and  after  any  acute  illness.  If  pos- 
sible, the  service  should  be  extended  so  that  examinations  may  be 
made  every  three  months.  Every  case,  whether  considered  nor- 
mal or  abnormal,  should  be  placed  under  the  supervision  of  the 
nurse  and  visits  should  be  made  to  the  child's  home  at  frequent 
intervals  so  that  environment  may  be  adjusted,  the  hygiene  of 
its  daily  life  regulated  and  all  possible  prophylactic  and  early 
corrective  measures  taken  to  insure  prevention  of  disease  and 
future  sound  health  for  the  child. 

5.  In  connection  with  the  dental  clinics,  a  system  of  oral  hygiene 
should  be  maintained,  and  all  children  of  pre-school  age  should 
receive  the  advantage  of  this  service.  It  has  been  proved  definitely 
that  proper  methods  of  oral  hygiene,  begun  in  early  childhood,  have  a 
more  definite  and  lasting  effect  in  preserving  the  teeth  than  any  future 
corrective  work  can  possibly  accomplish.  Moreover,  the  cost  of  proper 
oral  hygiene  is  only  a  fraction  of  the  cost  of  corrective  dental  work.  To  be 
effective,  oral  hygiene  should  be  commenced  before  the  child's 
second  teeth  have  begun  to  appear,  and  certainly  well  in  advance 
of  the  appearance  of  the  first  permanent  teeth — the  sixth  year 
molars. 

6.  In  the  pre-school  age  clinics  facilities  should  be  provided  for 
performing  Schick  tests  on  all  children  and  for  giving  toxin- 
antitoxin  injections  for  immunization  of  proved  susceptibles 
against  diphtheria.  The  period  before  five  years  of  age  is  the  time 
when  natural  immunity  to  diphtheria  is  at  its  lowest  and  when  the  death 
rate  from  this  disease  is  at  its  highest  point.      There  is  little  doubt  that 


A  Program  for  Child  Health  287 


this  disease  could  be  largely,  if  not  entirely,  eliminated  if  Schick  tests 
and  toxin -antitoxin  immunizations  of  non-immune  children  could  be 
carried  out  throughout  the  entire  child  population  under  five  years  of 
age. 

Child-Caring  Institutions 

Present  Status  and  Needs: 

There  are  in  Cleveland  nineteen  children's  institutions  with  a  capacity 
of  2,032  children.  In  addition,  about  800  more  children,  under  the  super- 
vision of  the  Humane  Society,  are  provided  for  in  boarding  homes  and  in 
free  homes  where  they  have  the  status  of  adopted  members  of  the  family. 

A  medical  survey  of  these  institutions  gave  the  following  results: 

1.  Only  three  out  of  a  total  of  nineteen  institutions  investigated  have  an 
entrance  physical  examination. 

2.  Only  three  have  an  admission  quarantine  to  prevent  new  entrants  from 
bringing  contagion  into  the  institution. 

3.  Eleven  have  ample  isolation  facilities;    eight  have  not. 

4.  Thirteen   have   adequate   hospital   facilities,    while   six  have   inadequate 
facilities,  or  none  at  all. 

5.  Not  a  single  institution  of  the  nineteen  investigated  conducts  a  periodic 
physical  re-examination. 

6.  Thirteen  of  the  homes  have  hospital  and  dispensary  affiliations,  while 
six  maintain  no  relationships  of  this  nature. 

7.  Children  are  allowed  as  visitors  in  seventeen  of  the  institutions  investigated. 
In  only  two  is  this  practice  prohibited. 

A  sanitary  survey  of  these  institutions  showed  a  great  variety  of  inade- 
quacies of  equipment  and  insanitary  conditions  prevailing  (For  details  see 
chapter  in  "Child-Caring  Institutions,"  Part  II.). 

RECOMMENDA  TIONS 

1.  The  licensing  of  all  child-caring  institutions  and  their  regular  and  ade- 
quate inspection  and  supervision  by  the  municipal  government  should  be  pro- 
vided for  through  the  Division  of  Health. 

2.  Extension  is  advised  of  the  boarding-out  system  in  private  homes,  under  compe- 
tent supervision.  Homes  offering  to  receive  children  to  board  should  not  be  allowed  to 
do  so  before  having  received  permits  fcr  the  purpose,  such  permits  to  be  issued  by  the 
Division  of  Health.  Permit  holders  should  be  kept  under  close  supervision  and  the  per- 
mits revoked  if  any  negligence  is  found  at  any  time.  As  rapidly  as  possible  provision 
should  be  made  so  that  every  mentally  normal  child  who  cannot  otherwise  receive  home 
care  may  be  placed  in  a  properly  licensed  private  home,  under  adequate  supervision,  and 
such  child  should  receive,  either  through  the  pre-school  age  facilities  of  the  health  cen- 


288  Hospital  and  Health  Survey 

ters  or  through  the  school  medical  inspection  of  the  public  and  parochial  schools,  the  same 
type  of  effective  health  supervision  that  is  given  to  children  whose  parents  are  alive  and 
able  to  provide  for  them. 

Children's  Dispensaries 

A  detailed  statement  of  existing  facilities,  the  needs  to  be  met  and  the 
remedies  proposed,  will  be  found  in  the  chapter  oh  "Dispensaries,"  Part  X. 

School  Health  Supervision 

Present  Status  and  Needs: 

School  health  supervision  in  Cleveland  must  be  considered  from  two 
angles:  school  medical  inspection  in  parochial  schools,  and  school  medical 
inspection  in  public  schools. 

School  Medical  Inspection  in  Parochial  Schools: 

There  are  about  35,000  children  attending  the  parochial  schools  in  Cleveland.  The 
authorities  of  these  schools  provide  no  medical  or  nursing  care  or  health  education,  either 
in  the  school  or  in  the  home.  In  March,  1917,  nurses  of  the  Division  of  Health  were 
assigned  to  duty  in  seventeen  parochial  schools.  In  1919-1920  this  work  was  carried  on 
in  twenty-one  parochial  schools.  Records  seem  to  show  that  9,323  pupils  in  these  schools 
received  a  physical  examination.  Notices  were  sent  to  the  parents  and  some  effort  was 
made  to  follow  up  the  children  found  to  have  defects.  No  records  are  available  to  show 
what  percentage  of  defects  the  nurses  had  corrected.  During  the  school  year  1919-1920 
the  total  number  of  parochial  schools,  sixty-eight  in  number,  with  a  registration  of  ap- 
proximately 35,000  pupils,  were  placed  under  the  supervision  of  these  nurses.  As  the 
staff  of  field  nurses  averages  only  about  fifty  and  as  they  have  their  work  at  the  health 
centers  in  addition  to  this  work  in  the  parochial  schools,  it  was  impossible  for  them  to 
carry  out  any  system' of  school  health  supervision  in  the  parochial  schools  that  could  be 
considered  at  all  adequate. 

One  observation  was  made  in  each  classroom  to  discover  evidences  of  contagious 
diseases.  Visits  were  made  once  a  week  to  each  school  and  a  certain  amount  of  absentee 
visiting  is  recorded.  No  provision  for  the  assignment  of  doctors  to  this  work  has  been 
made.  It  is  evident  that  the  work  is  not  well  organized  or  at  all  extensive  and  in  no  sense 
can  it  be  considered  an  adequate  system  of  health  supervision  of  the  children  in  the  schools 
in  question. 

School  Medical  Inspection  in  Public  Schools: 

Services  dealing  with  health  in  the  public  schools  in  Cleveland  are  carried  out  through 
four  distinct  groups:  (1)  a  Department  of  Medical  Inspection  under  the  control  of  a  Direc- 
tor who  is  on  part-time;  (2)  physical  education,  under  control  of  a  Director;  (3)  health 
education,  without  any  organized  or  central  direction,  and  (4)  sanitary  supervision,  under 
the  Director  of  Buildings. 

The  Directors  of  the  Departments  of  Medical  Inspection  and  Physical  Education 
report  to  an  Assistant  Superintendent  of  Schools,  while  the  Director  of  Buildings  is  under 
the  control  of  the  Director  of  Schools  or  chief  of  the  service  department  for  the  Board  of 


A  Program  for  Child  Health  289 


Education.  It  may  thus  be  seen  that  there  is  divided  responsibility  for  the  health  of  the 
school  children,  and  that  at  present  there  is  no  coordinated  program  of  such  type  that 
the  work  may  be  considered  effective. 

More  specific  consideration  may  be  given  to  these  matters  as  follows: 

/.   Medical  Inspection: 

This  department  is  organized  with  a  director,  who  is  responsible,  through  an  assistant 
superintendent,  to  the  Superintendent  of  Schools.  The  following  groups  of  employes 
and  functions  come  under  the  supervision  of  the  director  of  this  department: 

(a)  Medical  inspectors,  staff  nurses,  field  nurses  and  junior  health  workers. 

(b)  Clinics:  Dental  clinics  and  eye  clinics. 

(c)  Special  Classes:  Classes  for  the  blind,  school  for  the  deaf,  school  for  crip- 
pled children,  classes  for  mental  defectives,  open  air  classes,  classes  for 
tuberculous  children. 

(d)  Issuance  of  work  permits. 

(e)  Advisory  capacity  at  preventorium  (Children's  Fresh  Air  Camp)  and  the 
Boys'  Farm  at  Hudson. 

Medical  Inspectors: 

There  were  at  the  time  of  this  investigation  twenty-one  school  inspectors  with  a  total 
registration,  in  the  elementary  schools  and  junior  highs,  of  103,272  for  1919-1920.  This 
allows  one  medical  inspector  to  each  five  thousand  pupils.  These  inspectors  give  part  time, 
or  from  9  a.  m.  to  noon  five  days  a  week.  The  qualifications  for  this  position  have  not 
been  standardized,  other  than  that  a  degree  in  medicine  is  required.  The  director  inter- 
views the  candidates  personally  and  uses  his  judgment  as  to  the  applicants'  suitability  for 
the  work.  The  chief  incentive  of  many  of  the  force  is  interest  in  the  work  rather  than 
the  salary  paid,  which  is  low.  Each  inspector  is  responsible  directly  to  the  director,  as 
there  is  no  assistant  director.  Each  follows  a  schedule  which  has  been  prepared  at  the 
central  office  and  provides  for  a  visit  by  a  doctor  or  nurse  to  each  school  practically 
every  day.  The  inspector  may  not  visit  each  school  assigned  him  oftener  than  one  to 
three  times  a  week,  as  each  doctor  has  from  six  to  nine  schools  under  his  supervision. 

At  these  school  visits  the  doctor's  routine  is  as  follows: 

1.  Inspection  of  all  children  who  have  been  selected  and  referred  by  the 
teachers  as  possible  cases  of  illness. 

2.  Routine  physical  examination  of  pupils.  The  physical  examination  is  in 
reality  an  inspection.  It  seems  to  be  fairly  competent  as  far  as  examina- 
tion of  teeth,  tonsils  and  eyes  is  concerned,  but  the  rest  of  the  examination 
is  casual  and  hurried,  and  heart,  lungs,  joints,  musculature  and  hearing 
are  examined  only  in  special  instances.  Children  are  not  undressed,  nor 
are  height  and  weight  recorded.  Apparently  no  investigation  is  made  as 
to  the  health  habits  of  the  children,  nor  is  any  advice  in  general  health 
habits  given  at  the  time  of  the  medical  inspection.  It  is  evident  that 
the  so-called  "physical  examination"  of  the  children  is  of  a  superficial 
type  and  that  it  cannot  be  considered  either  thorough  or  satisfactory.  In 
fact,  it  does  not  warrant  the  name  "physical  examination,"  for  in  many 


"290  Hospital  and  Health  Survey 


instances  it  seems  to  amount  to  little  more  than  a  casual  inspection,  cer- 
tainly not  thorough  enough  to  discover  physical  defects  except  those  of  the 
most  obvious  types. 

Plans  are  under  way  to  adopt  the  recommendation  of  the  Survey  to 
improve  radically  this  department. 

School  Nurses: 

There  are  about  thirty  school  nurses  and  each  has  under  her  supervision  approxi- 
mately three  thousand  school  children.     School  nurses  have  the  following  duties: 

1.  To  assist  the  medical  inspectors  in  the  physical  examination  of  children. 

2.  To  inspect  all  pupils,  by  rooms.  This  is  done  usually  after  the  summer, 
Christmas  and  Easter  vacations,  when  the  children  are  inspected,  a  roomful 
at  a  time,  by  the  doctor  and  nurse  for  signs  of  communicable  diseases. 
Once  a  month  the  nurses  make  similar  inspections,  devoting  from  seven 
to  ten  minutes  to  an  entire  roomful  of  children. 

3.  To  secure  correction  of  physical  defects  found  in  the  physical  examina- 
tions by  means  of 

(a)  Notices  and  messages  to  parents. 

(b)  Consultations  with  parents  at  the  schools. 

(c)  Visits  to  homes. 

4.  To  maintain  a  dispensary  hour  in  each  school  for  treatments,  dressings, 
emergencies  and  inspection  of  children  returning  to  school  after  exclusion. 

5.  To  give  health  talks  to  individual  pupils  and  to  classes  in  classrooms. 

1.  Assisting  the  Doctors  in  Physical  Examinations: 

•  In  assisting  the  doctors  in  physical  examination  of  school  children,  the  work  of  the 
nurses  is  distinctly  clerical  in  character.  A  large  proportion  of  her  time  is  thus  taken 
from  strictly  nursing  duties  and  the  results  obtained  do  not  justify  the  use  of  nurses  for 
the  purpose. 

2.  Inspection  of  Pupils  in  Classrooms: 

The  nurses  spend  an  entire  hour  or  more  each  school  day  making  classroom  inspection  s 
of  the  children  for  the  purpose  of  detecting  communicable  diseases.  On  account  of  the 
preoccupation  of  the  nurses  with  other  duties,  even  this  necessarily  superficial  inspection 
can  be  repeated  only  at  intervals  of  about  four  weeks.  In  the  intervals  the  teachers  must 
be  relied  upon  to  notice  symptoms  and  refer  children  to  the  nurses  for  proper  care. 

3.  Correction  of  Physical  Defects: 

In  Cleveland  at  present  much  time  is  given  to  finding  defects  and  recommending 
treatment;  little  time  is  given  to  seeing  that  those  defects  are  remedied  and  the  child's 
mode  of  living  and  home  surroundings  are  improved.  Reliance  is  placed  largely  on  the 
sending  of  notification  to  the  parents  and  having  parents'  consultations  at  school.  The 
correction  of  physical  defects  and  the  elimination  of  those  home,  school  and  personal 
environmental  conditions  which  may  cause  physical  defects  are  among  the  most  impor- 
tant activities  of  the  school  nurses,  yet  at  the  present  time  the  unsatisfactory  results  of 
the  methods  used  are  apparent  from  the  report  of  the  Department  of  Medical  Inspection 
for  the  school  year  1917-1918,  where  it  is  shown  that  although  32,918  children  were  found 
to  have  physical  defects,  only  38.1%  of  these  are  reported  as  having  been  corrected.  It 
is,  moreover,  striking  to  note  that,  according  to  the  table  of  defects  found  and  corrected, 


A  Program  for  Child  Health  291 


corrections  were  almost  all  of  the  most  obvious  defects — those  of  teeth,  tonsils  and  eyes — 
while  those  defects  listed  as  anemia,  scoliosis,  poor  nutrition,  defects  of  the  extremities, 
chorea,  chest  defects,  discharging  nose,  cardiac  disease,  goitre  and  discharging  ears — a 
total  of  1,213  cases — showed  only  five  corrected.  For  the  32,918  children  found  defec- 
tive, the  nurses  had  only  6,397  consultations  with  parents,  with  possible  duplications 
included  in  this  number,  and  made  only  9,010  visits  to  the  homes,  thus  visiting  fewer 
than  one  out  of  every  three  defective  children  found.  This  small  number  should  be  in  part 
ascribed  to  the  fact  that  the  nurses  assisted  in  a  very  large  number  of  vaccinations  dur- 
ing the  year,  over  45,000  as  against  approximately  16,000  in  the  next  year.  The  figures 
contained  in  the  report  of  the  Department  of  Medical  Inspection  for  1918-1919  show  an 
improvement  in  the  correction  of  defects;  32,747  defects  were  found  and  14,295  or  43.6% 
were  corrected.  It  is  clearly  evident  that  the  essential  follow-up  work  to  obtain  proper 
care  and  treatment  for  these  children  is  almost  wholly  lacking.  It  is  of  no  practical  value 
to  discover  physical  defects  in  children  simply  for  the  gathering  of  statistical  data.  The 
true  test  of  efficiency  in  the  matter  of  preventing  and  correcting  physical  defects  in 
children  is  not  the  number  found  but  the  number  which  receive  proper  medical  and 
health  care.  It  is  evident  that  neglect  of  this  important  work  is  due  to  the  use  of  the 
nurses  in  so  many  other  duties  and  to  the  fact  that,  with  the  limited  staff,  there  is  little 
time  left  for  making  home  visits. 

An  important  innovation  in  the  field  of  preventive  medicine  and  remedy  of  physical 
defects  has  been  made  in  the  schools  of  Cleveland  following  the  demonstration  of  success 
in  the  schools  of  Akron,  Ohio;  namely,  the  detection  and  abatement  of  enlarged  thyroid 
glands  among  the  girls  of  10  years  and  over.  The  detection  is  simple,  by  direct  inspection 
supplemented  by  palpation  to  verify  the  presence  of  the  residual  stalk  and  the  central 
body  as  well  as  the  lateral  lobes.  Enlargement  is  found  in  about  80%  of  the  girls  of  10 
years  and  over,  unless  they  have  had  specific  treatment  under  their  family  physician. 
The  reduction  of  the  glandular  enlargement  to  normal  size  is  easily  accomplished  by  the 
use  of  small  doses  of  iodide  of  soda  in  aqueous  solution  for  a  week  or  ten  days  in  the  fal  1 
and  in  the  spring  of  the  year  until  the  age  of  16.  The  advice  is  given  on  a  printed  slip 
as  follows: 


Division  of  Medical  Inspection  and  Physical  Education 
BOARD  OF  EDUCATION,  CLEVELAND,  OHIO 

To  the  Parents  of  Bearer: 

Cleveland  is  located  in  a  goiterous  district.  About  one-third  of  our 
girls  in  the  public  schools  above  the  age  of  ten  years  have  some  degree  of 
enlargement  of  their  thyroid  glands  or  simple  goiter. 

The  expenditure  of  a  trifling  sum  yearly  will  prevent  this  affection. 
Three  grains  of  Iodide  of  Soda  taken  in  a  glass  of  water  once  a  day  for  ten  days 
in  the  fall  and  again  in  the  spring  will  prevent  goiter.  This  treatment  should 
be  carried  out  yearly  between  the  ages  of  11  and  16  years. 

Director, 

Medical  Inspection  Department. 

TAKE  THIS  HOME 


292  Hospital  and  Health  Survey 

That  surgical  treatment,  nutritional,  circulatory,  nervous  and  cosmetic  defects  are 
thus  avoided  for  these  children  in  the  future  by  such  corrective  medicinal  treatment  can 
hardly  be  doubted.  The  inconvenience  of  residence  in  the  goiterous  region  on  the  great 
glacial  plateau  is  easily  remedied  by  an  intelligent  application  of  the  facts  established  by 
physiological  research.  The  school  children  of  Cleveland  owe  much  to  the  studies  made 
in  this  field  by  Dr.  Marine  in  particular  and  by  others  whose  contributions  to  science  in 
the  field  of  physiological  chemistry,  clinical  medicine  and  physiology  have  built  up  the 
facts  upon  which  education  and  specific  treatment  are  now  based. 

4.  Maintenance  of  Dispensary  Hour  at  Each  School: 

Nearly  half  the  nurse's  time  is  spent  in  dispensary  work.  This  consists  in  assisting 
the  doctor  in  his  physical  examinations,  inspecting  children  and  doing  emergency  dress- 
ings and  treatments.  This  seems  to  be  a  high  percentage  of  time  for  this  work,  and  a  great 
part  of  it  is  not  properly  part  of  the  nurse's  duties  or  of  the  school  health  service.  The 
use  of  nurses  for  this  clerical  work  absorbs  a  large  proportion  of  their  time  and  takes  them 
away  from  their  essential  school  duties.  The  treatment  of  minor  illnesses  and  injuries 
takes  a  great  deal  of  time  and  should  properly  be  carried  out  at  dispensaries  located  out- 
side the  school  buildings.  The  use  of  nurses  for  this  work  for  practically  half  the  day 
reduces  the  efficiency  of  the  school  health  work  to  a  marked  degree. 

5.  Health  Talks  to  Individual  Pupils  and  to  Classes  in  Classrooms: 

While  the  nurses  are  supposed  to  give  individual  health  talks  to  the  pupils,  it  is  evi- 
dent that  the  dispensary  work  is  so  hurried  as  to  render  this  impossible.  As  a  general 
rule,  the  talks  given  are  of  a  very  hasty  and  superficial  character,  and  it  is  doubtful  whether 
they  make  any  very  lasting  impression  upon  the  children.  In  addition,  the  fact  that  the 
talk  is  given  to  the  child  in  school  and  not  made  the  subject  of  a  follow-up  visit  to  the 
home,  where  also  the  parent  or  guardian  may  be  talked  to,  would  seem  to  render  these 
talks  of  but  little  value. 

As  to  the  health  talks  to  classes  in  classrooms,  there  is  always  a  difference  of  opinion 
as  to  whether  they  should  be  given  by  people  who  know  how  to  teach  but  who  are  not 
necessarily  experts  in  the  subject  matter,  or  by  persons  who  are  experts  in  the  subject 
matter  but  who  do  not  know  how  to  teach.  It  would  seem  as  though  nurses  generally 
come  under  the  latter  classification.  In  the  talks  on  health  subjects  given  by  the  nurses 
in  the  classrooms,  a  wide  variation  of  ability  is  shown.  Some  of  the  nurses  are  quite 
competent  to  teach  the  subject,  while  others,  although  knowing  their  subject  well,  do  not 
know  how  to  teach.  The  present  unstandardized,  ungraded  and  unsystematic  methods 
tend  to  diminish  the  value  of  these  talks. 

Field  Nurses: 

Supervising  nurses  in  Cleveland  are  called  "field  nurses."  The  spirit,  intentions 
and  desires  are  excellent  and  their  ideas  seem  to  be  good.  There  are,  however,  too 
few  of  them  to  enable  them  to  visit  the  staff  or  school  nurses  at  sufficiently  frequent 
intervals.  Because  of  the  unusual  outside  demands  made  on  these  nurses  during  the 
past  year,  the  present  average  of  visits  was  only  two  in  a  year.  Last  year  several  of  the 
school  nurses  were  not  visited  at  all  by  the  field  nurses.  It  is  evident  that  the  question 
of  proper  supervision  is  not  clearly  understood  and  this  is  one  of  the  most  serious  weak- 
nesses in  the  system.  The  results  are  evident  in  the  nurses'  work,  which  has  tended  to 
become  routine  in  character,  often  lacking  in  originality,  in  vision,  in  social  spirit  and  in 


A  Program  for  Child  Health  293 

grasp  of  opportunity.  These  nurses  are  performing  their  duties  conscientiously,  but 
without  imagination.  It  is  felt  that  their  work  could  be  improved  if  more  time  could  be 
devoted  to  their  supervision. 

Junior  Health  Workers: 

These  employes,  of  a  type  which  seems  unique  to  the  city  of  Cleveland,  are  giving 
excellent  results.  They  are  well  educated  women  of  an  unusually  high  type,  and  have 
relieved  the  nurses  of  much  routine  work,  in  attending  the  doctor  during  physical  examina- 
tions, in  making  efforts  to  obtain  correction  for  dental  defects,  and  taking  children  to 
dispensaries.  These  junior  health  workers  are  paid  one  hundred  dollars  per  month.  They 
are  not  under  civil  service  regulations  but  are,  in  general,  women  of  excellent  training, 
college  graduates,  and  their  opportunities  could  be  increased  and  their  sphere  of  usefulness 
greatly  extended  with  resultant  advantage  to  the  system. 

Clinical  Facilities: 

There  are  certain  clinical  facilities  available  in  the  schools: 

1.  Emergency  treatment  in  the  dispensaries. 

2.  Dental  clinics.  These  are  held  in  six  schools  for  half  of  each  school  day. 
The  work  is  mainly  on  first  and  second  grade  children.  Older  children  are 
sent  to  their  own  dentists  or  to  the  dental  college  clinic. 

3.  Eye  clinics.  There  are  two  eye  clinics,  one  on  the  east  side  at  Brownell 
School  and  the  other  on  the  west  side.  In  addition,  there  is  a  trachoma 
clinic  in  the  Murray  Hill  School. 

Nose,  throat,  ear,   skin  and   orthopedic   cases  are  sent  to  private    phy- 
sicians, hospitals  or  clinics. 

Facilities  for  dentistry  and  the  treatment  of  abnormal  eye  conditions  are  inadequate. 
In  this  respect,  however,  Cleveland  is  as  well  equipped  as  most  cities  in  the  country.  The 
value  of  dental  clinics,  particularly  for  prophylactic  work  and  oral  hygiene,  has  not  been 
widely  recognized  in  the  past.  Plans  have  been  made  by  the  Department  of  Medical 
Inspection  to  increase  greatly  this  branch  of  the  work  during  the  coming  year  by  the 
appointment  of  capable  assistants  to  the  school  dentists  and  by  training  them  as  dental 
hygienists.  Also,  there  can  be  no  criticism  of  the  maintenance  of  special  clinics  for  the 
treatment  of  trachoma.  The  Department  lacks  the  services  of  an  oculist  to  guide  policies 
and  supervise  trachoma  work.  That  is  a  contagious  disease  and  its  elimination  is  dis- 
tinctly a  function  of  the  city  authorities. 

Special  Classes: 

1.  Open  Air  Classes.  There  are  nineteen  fresh  air  rooms  in  various  schools, 
caring  for  about  two  hundred  and  seventy  pupils.  In  some  districts  the 
fresh  air  classes  can  take  care  of  practically  all  applicants,  but,  in  general, 
there  are  always  more  pupils  than  can  be  accommodated.  These  classes 
care  for  anemic  and  sickly  children  and  those  exposed  to  tuberculosis. 
Even  limiting  the  attendance  to  cases  of  these  types,  it  is  clearly  evident 
that  the  present  fresh  air  classes  are  wholly  inadequate  to  care  for  the  chil- 
dren who  are  in  urgent  need  of  this  type  of  care. 

Admission  to  these  classes  is  decided  upon  by  the  doctors  and  nurses  who 
go  through  the  classes  and,  with  the  cooperation  of  the  teachers,  pick   out 


294  Hospital  and  Health  Survey 

children  who  are  considered  to  need  this  kind  of  treatment.  The  children 
selected  include  those  who  are  lagging  and  are  not  doing  well  and  those 
who  come  from  home  with  insufficient  food.  Each  child  receives  a  com- 
plete physical  examination  before  admission  to  the  class.  Underweight 
and  malnutrition  are  considered  to  be  sufficiently  evident,  without  weigh- 
ing, as  scales  are  not  provided  by  the  Board  of  Education. 

The  health  routine  in  the  fresh  air  classes  is  under  the  control  of  the  Direc- 
tor of  the  Department  of  School  Medical  Inspection.  This  official  does  not 
appoint  the  teachers,  however,  but  acts  in  an  advisory  capacity  to  them. 
The  nurse  takes  the  temperature  of  the  children  in  these  rooms  twice  a 
month.  If  the  temperature  is  over  ninety-nine  degrees  in  any  case,  she 
takes  it  every  day  until  it  returns  to  normal.  She  tries  to  have  the  chil- 
dren weighed  once  a  month.  A  loss  of  two  and  a  half  pounds  is  reported 
to  the  doctor.  All  possible  efforts  are  made  to  have  physical  defects  cor- 
rected. 

As  far  as  possible,  these  children  have  a  rest  period  of  at  least  twenty 
minutes  during  the  noon  hour  and  additional  rest  periods  are  provided  for 
individual  pupils  when,  in  the  judgment  of  the  school  doctor,  such  rest  is 
deemed  necessary.  Cots  are  provided  by  the  Board  of  Education  for 
these  rest  periods.  Physical  exercise  for  these  children  includes  only 
light  gymnastics  and  games,  with  much  emphasis  on  deep  breathing. 

Children  in  the  open  air  classes  receive  a  lunch  twice  a  day,  consisting  of 
milk,  cocoa,  graham  crackers,  furnished  by  the  Federated  Women's 
Clubs  and  the  Board  of  Education  jointly. 

2.  School  for  the  Deaf.  One  school  for  the  deaf  is  maintained.  In  this 
school  seventeen  teachers  care  for  about  two  hundred  and  fifty  pupils. 
Children  are  referred  to  the  school  by  the  school  doctors  when  they  find 
cases  of  markedly  defective  hearing.  Children  with  slight  defects  of  this 
kind  or  whose  defects  are  under  treatment  usually  are  kept  in  their  regular 
classes.  The  present  facilities  would  seem  to  be  adequate,  both  in 
quality  and  in  their  provision  for  the  number  of  children  needing  this 
kind  of  care. 

3 .  Classes  for  the  Blind.  There  are  classes  for  the  blind  in  twelve  different 
schools.  The  Department  of  School  Medical  Inspection  selects  the  chil- 
dren for  these  classes.  In  addition,  a  number  of  sight-saving  classes  are 
maintained.  A  child  is  sent  to  a  sight-saving  class  when  it  is  felt  that 
the  ordinary  routine  of  school  work  would  damage  its  eyesight.  These  chil- 
dren receive  a  complete  physical  examination.  Routine  inspection  is 
also  made  in  these  classes.  It  would  seem  that  the  provisions  for  caring 
for  this  class  of  cases  are  adequate. 

4.  School  for  Crippled  Children.  While  a  special  school  for  crippled  children 
is  maintained,  there  is  always  a  waiting  list  for  entrance  and  the  authori- 
ties have  recognized  the  need  for  increasing  the  facilities.  Children  are 
referred  to  this  school  by  the  medical  inspectors.  Canvass  is  made  also 
of  all  schools  in  the  city  for  children  who  should  receive  this  type  of  treat- 
ment.    Busses  are  provided  by  the  Board  of  Education  for  transporting 


A  Program  for  Child  Health  295 


these  children  to  and  from  their  homes  and  to  and  from  the  dispensaries. 
It  is  evident  that  the  facilities  are  inadequate  and  that  this  work  should 
be  extended.  It  is  planned  to  build  a  new  school  especially  adapted  to 
the  needs  of  these  children. 

5.  Classes  for  Correction  of  Speech  Defects.  Eighty-one  classes  for  correction 
of  speech  defects,  with  an  enrollment  of  1,182  pupils,  are  maintained.  Pro- 
vision for  the  correction  of  these  defects  by  class  instruction  seems  to  be 
adequate. 

6.  Nutrition  Classes.  Special  nutrition  classes  have  been  established  in  two 
schools.  However,  the  work  applies  only  to  a  small  number  of  pupils  and 
is  intensive  in  character.  As  is  well  known,  the  causes  of  undernourish- 
ment are  many  and  complex,  and  intensive  work,  taking  each  child  indi- 
vidually and  giving  it  unusual  care,  undoubtedly  gives  the  best  results. 
At  the  same  time,  it  must  be  remembered  that  undernourishment  is  one 
of  the  most  extensive  and  serious  diseases  met  with  during  child  life.  The 
statistics  for  many  cities  and  for  the  country  at  large  show  that  twenty  to 
twenty-five  per  cent  of  the  children  of  school  age  suffer  from  some  degree 
of  malnutrition.  It  is  stated  that  plans  are  under  way  for  extension  of 
the  special  nutrition  work  throughout  the  schools. 

7.  Provision  for  Mental  Hygiene.  Thirty  schools  have  classes  for  mentally 
defective  children.  This  subject  is  dealt  with  in  the  special  report  on 
Mental  Hygiene,  Part  VI. 

8.  Cardiac  Classes.  There  is  no  provision  for  children  with  cardiac  disease. 
The  need  of  special  provision  for  the  cardiac  child  in  and  out  of  school  is 
described  in  the  chapter  dealing  with  this  problem,  Part  II. 

School  Dispensaries: 

Each  school  is  provided  with  a  so-called  "dispensary"  where  emergency  treatments 
are  given  for  minor  injuries  or  ailments.  In  these  school  dispensaries,  emphasis  is  laid 
upon  corrective  rather  than  upon  preventive  health  work  or  health  education. 

Conferences: 

Doctors  meet  every  two  weeks  with  the  Director  of  the  Department.  At  these  meet- 
ings papers  on  the  Schick  test,  goitre,  contagious  diseases  and  so  forth,  are  read  and 
discussed.  The  nurses  meet  each  week.  The  whole  group  meets  from  time  to  time  for 
special  lectures.  To  help  the  nurses  special  courses  are  given,  tuition  free,  at  the  Summer 
Session  of  the  Normal  School. 

Health  Records: 

The  health  records  of  the  children  are  deficient.  Neither  the  nurses  nor  the  doctors 
keep  these  records  filled  in  properly  and  many  of  the  cards  do  not  show  the  essential  points 
which  would  be  of  value  in  determining  the  type  of  health  care  the  child  needs.  At  the 
present  time  the  cards  do  not  seem  to  serve  any  useful  purpose.  Such  records,  however, 
should  be  one  of  the  most  important  features  of  a  well-organized  system  of  school  health 
supervision.  A  cumulative  record  card,  having  on  it  the  social  history,  physical  examina- 
tion and  follow-up,  is  being  prepared  by  a  committee  of  the  Department  of  School  Medical 
Inspection.     The  child's  individual  record  is  kept  in  the  classroom.     It  is  very  brief  and 


296  Hospital  and  Health  Survey 

tells  little  of  what  has  been  done  for  the  child.  The  doctor's  orders  are  entered  on  this 
card,  but  the  work  done  by  the  nurse  is  usually,  although  not  always,  entered  on  the  cor- 
rection slip  in  her  file.  Home  visits  are  recorded  on  still  another  card,  so  that  any  effort 
to  check  the  nurse's  accomplishment  against  the  doctor's  recommendations  is  almost 
hopeless.  The  individual  health  records  of  the  children  are  kept  on  the  teacher's  desk. 
They  are  suppesed  to  keep  the  teacher  informed  of  the  children's  physical  condition. 
These  records  follow  the  children  from  class  to  class,  together  with  the  school  records. 
The  teachers  seem  uninterested,  however,  because  nothing  appears  on  these  records  that 
would  give  them  a  clear  idea  of  the  children's  physical  condition. 

The  nurses  have  a  habit  of  using  the  ordinary  correction  slips  for  making  notes  of 
home  visits.  This  method  is  extremely  bad,  as  it  does  not  make  for  permanency  and 
there  is  absolutely  no  way  in  which  such  records  can  be  made  the  basis  of  analysis  of  work 
done  and  results  obtained.  The  absence  of  monthly  reports  of  the  work  of  the  nurses  is 
also  a  factor  in  making  it  difficult  to  show  what  she  has  actually  accomplished.  It  is 
doubtful  whether  any  of  the  nurses  have  any  idea  of  the  amount  of  work  they  do  every 
month  and  the  amount  that  is  left  undone  because  of  the  number  of  children  handled. 

Neglect  of  Statistics  in  Regard  to  Physical  Defects. 

In  common  with  most  systems  of  school  medical  inspection,  particular  emphasis 
is  laid  upon  the  number  of  defects  found  and  the  number  corrected.  In  this  regard,  how- 
ever, the  records  of  Cleveland  are  not  complete.  It  is  evident  that  results  obtained  in 
cases  of  physical  defects  are  not  recorded  on  many  of  the  cards.  It  is  impossible,  there- 
fore, to  state  the  actual  percentage  of  corrections  obtained.  Of  two  hundred  cards  studied 
it  was  found  that  15.2 %  of  the  defects  found  were  recorded  as  corrected.  The  report  of 
the  Department  of  School  Medical  Inspection,  however,  states  that  38.1%  of  the  defects 
found  were  corrected.  This  discrepancy  is  obviously  due  to  incompleteness  in  the  records 
as  available  to  the  investigator. 

Supervision  of  Control  of  Communicable  Diseases! 

Although  minor  complaints  have  been  recorded  about  the  failure  of  nurses  to  take 
cultures  in  cases  of  sore  throat,  there  is  no  evidence  to  show  that  the  doctors  and  nurses 
of  the  Department  of  Medical  Inspection  are  not  carrying  on  the  work  with  reference  to 
the  control  of  communicable  diseases  in  a  satisfactory  manner.  There  seems  to  be  good 
cooperation  between  the  Department  of  School  Medical  Inspection  of  the.  Board  of  Edu- 
cation and  the  Division  of  Health  in  this  particular  and  the  present  regulations,  if  enforced, 
are  adequate  to  protect  the  children  and  the  public. 

2.  Physical  Training: 

The  Department  of  Physical  Training  has  charge  of  the  physical  training  of  children, 
their  exercise  and  athletics.  In  addition*,  it  makes  a  certain  number  of  physical  examina- 
tions of  children  in  the  junior  high  schools  and  in  the  high  schools.  There  is  no  definite 
cooperation  or  coordination  of  this  work  with  the  Department  of  School  Medical  Inspec- 
tion. Plans  are  under  way  for  the  coordination  of  these  two  departments.  School 
medical  inspection,  as  it  is  commonly  understood,  does  not  exist  in  the  high  schools.  It 
is  stated  that  all  pupils,  before  they  are  admitted  to  the  physical  training  classes  in  the 
high  schools  and  junior  high  schools  are  examined  by  the  teachers  of  physical  training. 
This  examination  covers  heart,   lungs,   eyes,   back,   weight,   etc.     It  is  stated,   however, 


A  Program  for  Child  Health  297 


that  not  nearly  all  the  girls  have  been  examined.  The  elementary  school  health  records 
do  not  follow  the  children  into  the  junior  high  schools  or  the  high  schools;  therefore  they 
are  not  used  by  the  Department  of  Physical  Training. 

3.  Health  Education: 

At  the  present  time  this  work  is  carried  on  in  the  following  ways: 

(a)  Through  occasional  classroom  talks  on  health  topics  given  by  nurses  of 
the  Department  of  School  Medical  Inspection. 

(b)  Through  individual  instruction  of  the  children  in  the  schools  by  physi- 
cians and  nurses  of  the  Department  of  School  Medical  Inspection. 

(c)  Through  instruction  by  the  nurses,  in  the  seventh  and  eighth  grades,  on 
the  subject  of  care  of  babies. 

(d)  The  curriculum  in  the  grammar  grades  provides  for  two  forty-minute 
periods  a  week  in  physiology  and  hygiene.  No  material  is  provided 
the  teachers  for  giving  this  course. 

(e)  There  is  instruction  in  the  high  schools  in  physiology,  botany,  cooking, 
chemistry,  social  problems  and  physical  training.  These  courses, 
except  physical  training,  are  elective. 

In  actual  practice,  according  to  conferences  held  with  various  teachers  and  principals 
little  or  no  work  in  hygiene  is  carried  out  in  the  elementary  schools.  The  whole  matter 
depends  upon  the  initiative  of  the  individual  teachers.  In  the  seventh  and  eighth  grades 
an  outline  has  been  provided,  but  the  teachers  are  not  obliged  to  follow  it,  and  in  the  cases 
of  the  teachers  with  whom  the  matter  was  discussed,  very  little  of  it  had  been  used.  Many 
of  the  principals  and  teachers  stated  that  they  are  eager  to  have  definite  material  furnished 
them  from  which  a  course  in  child  hygiene  could  be  given.  In  the  high  schools,  the  work 
of  health  education,  while  claimed  to  be  thorough,  does  not  seem  to  be  standardized.  It 
is  stated  that  points  on  personal  hygiene  and  sanitation  are  covered  more  by  chance  than 
premeditation,  that  correlation  between  the  teaching  departments  is  weak,  and  that  it  is 
difficult  to  tell  how  much  overlapping  of  courses  exists.  The  general  feeling  among  the 
teachers  seemed  to  be  that  there  is  great  need  for  a  standardized  hygiene  outline — some- 
thing systematic,  clear  and  concise. 

Examination  of  Teachers: 

Each  teacher's  contract  contains  a  requirement  that  she  shall  receive  a  physical  ex- 
amination. The  Director  of  the  Department  of  School  Medical  Inspection  stated  that 
the  teachers  and  custodians  had  a  thorough  physical  examination  two  years  ago,  given 
partly  by  the  school  physicians  and  partly  by  outside  physicians  of  the  city.  He  stated 
also  that  no  examination  has  been  made  of  is  contemplated  of  other  employees  of  the 
Board  of  Education,  but  that,  in  his  opinion,  such  a  procedure  would  be  desirable  and  that 
there  should  be  a  physical  examination  of  teachers  at  least  every  year. 

4.  Sanitary  Supervision: 

Sanitary  supervision  in  the  schools  is  primarily  under  the  Department  of  Buildings. 
This  department  is  directly  responsible  to  the  Director  of  Schools  or  the  Chief  of  the  Serv- 
vice  Department  of  the  Board  of  Education.  The  actual  work  is  carried  out  by  a  group 
of  employes  known  as  "custodians,"  who  are  responsible  to  the  supervising  custodians, 
who,  in  turn,  report  directly  to  the  Director  of  Buildings.     Various  sanitary  standards  for 


298  Hospital  and  Health  Survey 

sweeping,  dusting,  care  of  water  closets  and  drinking  fountains,  provision  of  soap  and 
towels,  control  of  temperature  and  ventilation  of  classrooms,  have  been  outlined  by  the 
Board  of  Education.  The  Director  of  Buildings  states  that  the  supervising  custodians 
try  to  make  sanitary  inspections  of  the  schools  twice  a  month,  and  that  some  buildings 
which  give  a  good  deal  of  trouble  are  visited  more  frequently. 

(a)  Ventilation: 

While  the  operation  of  the  ventilating  systems  is  placed  under  the  control  of  the 
custodians,  the  law  of  the  state  determines  the  type  of  ventilation  that  must  be  used.  It 
is  stated  that  there  are  old-fashioned  gravity  heat  and  open  window  ventilation  in  sixty 
to  seventy  schools.  There  is  shut  window,  forced  draft  ventilation,  which  is  the  policy 
of  the  department  in  all  new  plants,  in  fifteen  to  twenty  schools.  Not  more  than  eight  or 
ten  schools  have  provision  for  humidification.  One  school  has  air  washers.  When  the 
mechanically  operated  systems  are  working  the  windows  in  the  schools  cannot  be  opened 
without  interfering  with  the  ventilating  systems. 

Open  Window  vs.  Mechanical  Methods  of  Ventilation.  Proof  is  available  that  children 
in  open  air  classrooms  or  children  in  classrooms  ventilated  by  open  windows  will  increase 
in  weight  and  strength,  that  conditions  of  undernourishment  may  be  overcome  and  sound 
health  re-established  and  that  respiratory  diseases  may  be  prevented  if  children  receive 
the  advantages  of  such  care.  In  view  of  these  established  facts,  it  is  difficult  to  under- 
stand why  fresh  air  in  abundance,  by  means  of  open  window  ventilation,  is  not  made 
available  in  all  classrooms.  From  the  economic  point  of  view,  the  establishment  of  open 
window  ventilation  is  not  only  possible  but  desirable.  Official  statements  have  been 
made  that  the  cost  of  any  school  building  in  Cleveland  will  average  $30,000.00  per  class- 
room. It  has  been  stated  by  sanitary  engineers  that  the  cost  of  installing  heating  and 
ventilating  plants  in  school  buildings  amounts  to  fifteen  per  cent  of  the  cost  of  construc- 
tion. The  main  objection  that  has  been  raised  against  the  open  window  system  of  ventila- 
tion is  the  increased  amount  of  heat  required  and  the  consequent  expense  for  additional 
fuel.  It  may  be  estimated  that  the  approximate  cost  of  the  ventilating  plant  is  seven  and 
a  half  per  cent  of  the  total  cost  of  construction  of  the  building.  If  the  cost  of  each  class 
room  is  $30,000.00,  it  may  be  seen  that,  in  addition  to  the  ordinary  appropriations  for  fuel, 
there  would  be  a  sum  amounting  to  $2,250.00,  available  for  extra  fuel  before  the  total  cost 
of  the  classroom  ventilated  by  open  window  ventilation  would  reach  the  estimated  cost  of 
the  room  ventilated  by  artificial  means.  From  the  point  of  view  of  health,  open  window 
classrooms  are  essential.  The  cost  is  not  excessive  and  in  all  probability  it  is  not  greater 
than  the  present  cost  of  school  maintenance. 

(6)  General  Construction. 

The  regulations  governing  general  construction  of  classrooms  require  that  sixteen 
square  feet  of  floor  space  be  allowed  for  each  child.  The  color  of  the  walls  and  ceilings  is 
a  standard  soft  gray.  Maple  flooring  is  required  to  be  used  in  new  classrooms,  and  tiles 
in  corridors.  In  new  buildings  these  regulations  have  been  complied  with,  but  they  are 
not  common  in  old  buildings. 

(c)   Temperature. 

Each  classroom  is  supposed  to  be  equipped  with  a  thermometer,  but  no  provision  has 
been  made  for  systematic  testing  of  the  thermometers,  and  the  reporting  of  variations  of 
temperatures  is  very  generally  left  to  the  principals.     A  temperature  of  sixty-five  to  sixty- 


A  Program  for  Child  Health  299 


eight  degrees  is  recommended.  In  many  instances  investigated,  however,  the  temperature 
was  found  to  be  distinctly  above  this  standard.  Upon  inspection  in  various  schools  the 
temperature  was  found  to  be  as  follows: 


Total  Number  of 

Temperature 

Classrooms 

Per  Cent 

Under  70  degrees  F. 

14 

20.9 

70  degrees  F. 

19 

28.3 

71  degrees  F. 

2 

2.9 

72  degrees  F. 

11 

16.4 

73  degrees  F. 

7 

10.4 

74  degrees  F. 

11 

16.4 

75  degrees  F. 

1 

1.5 

76  degrees  F. 

2 

2.9 

Total- 

67 

Outside  temperature  was  forty -five  degrees  F.  when  forty-three  of  these  temperatures 
were  recorded,  forty-nine  degrees  F.  when  three  were  read,  forty-three  degrees  F.  when 
nine  were  read,  twenty-nine  degrees  F.  when  seven  were  read  and  thirty-eight  degrees  F. 
when  five  were  read. 

Principals,  nurses,  physicians  and  custodians  interviewed  seemed  more  or  less  inter- 
ested in  the  temperature,  reporting  that  "they  looked  at  the  thermometer  when  in  the  room," 
but  no  regular  inspection  of  the  thermometers  in  the  rooms  was  found  to  be  provided 
for.  Responsibility  for  the  temperature  of  the  room  seems  to  lie  between  the  teacher 
and  the  custodian,  and  is  a  more  or  less  constant  source  of  friction. 

(d)  Lighting: 

The  state  law  requires  that  the  relation  of  window  space  to  floor  area  in  classrooms 
shall  be  as  5  to  21.  In  the  construction  of  new  buildings,  rooms  are  lighted  from  the 
left  or  from  the  left  and  rear.  Window  shades  are  of  a  new  standard  type,  matching 
the  indoor  paint.  Plans  are  in  preparation  for  improving  the  lighting  of  rooms  now  in- 
adequately lighted.  In  rooms  where  the  lighting  is  artificial,  the  system  is  semi-indirect, 
allowing  six  hundred  watts  per  room  with  two  candle  power  on  desks. 

(e)  Seating: 

While  seating  adjustments  in  classrooms  are  taken  care  of  by  the  custodians  at  the 
request  of  the  principals,  inspections  and  requests  for  special  adjustments  are  supposed  to 
be  made  both  by  teachers  and  by  the  Department  of  School  Medical  Inspection.  About 
fifty  per  cent  of  the  schools  are  equipped  with  adjustable  seats.  Forty  per  cent  of  these 
schools  have  what  are  known  as  "shifting"  classes,  so  that  the  seats  are  not  continuously 
occupied  by  the  same  pupils. 


300  Hospital  and  Health  Survey 

(f)  Cubic  Air  Capacity: 

The  state  law  covers  the  distribution  of  cubic  air  capacity  and  floor  space.  The 
number  of  children  allowed  in  a  room  about  24  x  28  is  now  forty-two  (eighteen  square  feet 
per  capita).  The  ordinary  system  of  ventilation  allows  for  changing  the  air  in  these  class- 
rooms six  times  per  hour.  This  change  of  air  is  recorded  by  a  meter  which  is  checked  up 
by  the  Department  of  Buildings.  Inspection  of  the  proper  functioning  of  the  ventilating 
system,  to  check  up  the  required  number  of  changes  of  air  per  hour,  is  made  by  the  super- 
vising custodians. 

(g)  Blackboards: 

In  new  schools  blackboards  are  generally  adjusted  in  height  according  to  the  age  of 
the  child.  These  adjustments  have  not  been  completed,  however,  and  at  the  present 
time  a  number  of  schools  still  need  to  have  their  blackboards  replaced  at  the  proper  heights. 

(A)  Cleaning: 

Definite  rules  are  given  to  the  custodians  with  regard  to  sweeping,  dusting,  window- 
washing,  scrubbing,  etc.  Thorough  inspections  as  to  cleaning  are  made  in  September, 
at  Christmas  and  in  the  spring.  The  custodians  are  supposed  to  visit  classrooms  at  least 
once  a  month,  and  more  often  if  conditions  warrant.  Five  or  six  schools  are  equipped  with 
vacuum  cleaning  systems. 

(i)  Drinking  Facilities: 

All  schools  are  equipped  with  drinking  fountains,  but  not  every  school  has  as  many 
fountains  as  the  number  of  children  requires.  Practically  all  these  fountains  are  located 
in  basements.  They  are  of  standard  type,  with  pressure  jet.  In  the  type  of  fountain  used, 
the  flow  of  water  through  the  outlets  can  be  regulated  to  the  water  pressure,  but  in  many 
cases  the  fountains  investigated  did  not  have  sufficient  force  to  obviate  the  danger  of  com- 
municating disease.  In  some  of  the  fountains  seen  the  force  was  scarcely  sufficient  to 
carry  the  water  over  the  side  of  the  nozzle.  The  greatest  force  in  any  fountain  seen  was 
only  sufficient  to  raise  a  stream  about  two  and  one-half  inches.  All  fountains  seen  were 
vertical  in  type.  Some  had  a  continuous  stream,  while  in  others  it  was  necessary  to  turn 
on  the  water.  It  was  impossible  to  place  any  responsibility  for  the  control  of  the  condi- 
tion of  these  fountains,  although  the  matter  of  adjustment  of  the  proper  functioning  of 
the  fountains  as  to  pressure  and  cleanliness  is  supposed  to  be  left  to  the  custodian  of  the 
building. 


Summary  of  Drinking  Fountains  Inspected 


Per  Cent 
12.7 

8.4 
22.6 
16.9 

7.0 
11.3 

7.0 
14.0 


71  99.9 


Number  Inspected 

Height  of  Water 

9 

Practically  no  force 

6 

Min. 

16 

Kin. 

12 

Min. 

5 

1    in. 

8 

iy2m. 

5 

2       in. 

10 

2  Min. 

A  Program  for  Child  Health  301 

It  will  be  seen  that  only  twenty-one  per  cent,  or  about  one-fifth,  of  all  the  fountains 
had  a  force  of  two  inches  or  over,  which  the  Department  of  Buildings  gave  as  the  standard 
to  be  achieved,  and  certainly  desirable  in  the  interest  of  health  protection. 

(j)   Toilets: 

One  toilet  is  allowed  for  each  fifteen  girls  and  one  for  each  twenty-five  boys.  The 
number  now  provided  is  below  the  standard  required  by  the  state  law.  Inspection  of  the 
toilets  is  made  by  the  Department  of  School  Medical  Inspection  once  a  month,  and  some 
physicians  also  stated  that  they  made  periodic  investigations.  Other  physicians  stated 
that  they  had  no  responsibility  in  the  matter.  No  report  of  conditions  found  is  registered 
unless  complaint  is  made.  Unsatisfactory  conditions  are  reported  either  to  the  custodian, 
the  principal  or  to  the  Department  of  School  Medical  Inspection. 

RECOMMEND  A  TIONS 

School  Medical  Inspection  in  Parochial  and  Private  Schools: 

Parochial  Schools:  Provision  should  be  made,  either  in  the  budget  of  the 
Division  of  Health  or  through  private  contribution,  for  immediate  extension 
of  the  school  medical  inspection  service  to  all  parochial  school  children  in  the 
city  of  Cleveland.  There  are  now  about  thirty-five  thousand  children  in  attend- 
ance at  these  schools.  If  the  city  cannot  appropriate  sufficient  funds  at  the 
present  time,  it  would  be  very  desirable  if  the  parochial  school  authorities  could 
undertake  the  work  themselves,  but,  ultimately,  it  should  be  carried  on  by  the 
Division  of  Health.  It  is  evident  that  the  type  of  health  supervision  which  has  been 
shown  to  be  so  essential  for  children  in  the  public  schools  must  be  equally  essential  and 
desirable  for  children  in  the  other  free  schools  of  the  city.  Their  needs  in  this  respect 
should  no  longer  be  neglected,  nor  should  there  be  any  discrimination  practised  in  the 
matter  of  health  supervision  against  any  group  of  children  who  are  receiving  instruction 
in  any  schools. 

Private  Schools:  In  discussing  the  question  of  health  of  school  children,  a 
point  has  arisen  which  may  not  be  considered  within  the  scope  of  this  particular 
inquiry,  nevertheless,  as  the  health  of  all  children  of  the  city  of  Cleveland  must 
be  considered  in  any  adequate  program  for  child  hygiene,  it  is  recommended  that 
rules  and  regulations  be  drawn  up  by  the  Division  of  Health  for  the  sanitation 
and  hygiene  of  the  private  schools  of  the  city,  and  that  standard  methods  of  health 
supervision  be  devised,  also,  in  cooperation  with  the  private  sohool  authorities, 
and  that  they  be  put  into  effect  in  the  private  schools  under  the  auspices  and  at 
the  expense  of  the  schools  in  question. 

School  Medical  Inspection  in  Public  Schools: 

Much  of  the  work  carried  on  for  the  health  of  the  children  in  the  public  schools  of 
Cleveland  is  of  an  extremely  high  type  and  warrants  commendation.  The  present  form 
of  organization,  however,  is  a  great  drawback  to  the  efficiency  of  the  work  and,  in  addi- 
tion, there  are  numerous  points  in  connection  with  the  various  types  of  work  where  changes 


302  Hospital  and  Health  Survey 

are  indicated.  Lack  of  coordination  of  the  different  types  of  health  work  is  a  serious 
detriment.  There  are  many  points  of  overlapping  of  function.  For  instance,  the  cus- 
todians are  responsible  for  the  sanitary  and  hygienic  maintenance  of  the  school  buildings, 
yet  it  is  apparent  that  control  of  proper  ventilation,  adjustment  of  seats,  attention  to 
drinking  fountains  and  toilets,  and  general  sanitary  surveys,  with  adjustment  of  com- 
plaints, are  left  to  the  sporadic  attention  of  teachers,  doctors  and  nurses.  This  neglect 
to  fix  definite  responsibility  and  to  have  well-directed,  central  control  is  manifest  through- 
out the  system. 

In  order  that  the  health  of  children  of  school  age  in  Cleveland  may  receive  adequate 
protection,  the  following  program  of  reorganization,  readjustment  and  the  addition  of 
new  activities  is  suggested: 

Organization: 

There  should  be  coordination  of  all  services  dealing  with  health;  that  is, 
the  Department  of  School  Medical  Inspection  and  the  Department  of  Physical 
Training,  the  Department  of  Sanitary  Supervision  and  the  teaching  of  health 
education  should  be  under  the  control  of  a  single  individual,  an  assistant  super- 
intendent of  schools.  This  employe  should  be  a  full-time  employe,  preferably 
a  physician,  at  a  suitable  salary.  The  department  might  be  called  the  "Depart- 
ment of  Health  Supervision  of  School  Children."  The  director  of  this  depart- 
ment should  be  in  full  charge,  and  there  should  be  two  Assistant  Directors,  one 
in  charge  of  the  work  of  school  medical  inspection  and  one  in  charge  of  physical 
training.  The  Director  of  School  Custodians  should  be  under  the  jurisdiction  of 
the  Director  of  Health  Supervision  of  School  Children,  and  the  control  of  subject 
matter  for  health  education  should  be  placed  with  the  Bureau  of  School  Medical 
Inspection. 

Specific  recommendations  are  offered  as  follows: 

School  Medical  Inspection: 

1.  Personnel: 

The  number  of  school  medical  inspectors  should  be  increased  so  that  there 
is  one  doctor  for  every  three  thousand  children.  There  should  be  included  on 
the  staff  an  oculist  who  would  act  as  consultant  in  regard  to  trachoma  cases. 
The  number  of  nurses  should  be  increased  so  that  there  is  one  nurse  for  every  two 
thousand  children.  The  number  of  junior  health  workers  should  be  increased 
so  that  there  is  one  for  each  nurse. 

2.  Duties: 

(a)  Duties  of  School  Doctors: 

/.•  Sanitary  Surveys: 

At  the  beginning  of  each  term  the  school  doctor  should  make  a  complete 
sanitary  survey  of  each  school  under  his  jurisdiction.      This  survey  should  be  fol- 


A  Program  for  Child  Health  303 

lowed  up  by  a  report  outlining  conditions  of  sanitation  and  hygiene  found  in 
each  school  and  classroom,  calling  attention  to  any  changes  or  readjustments 
to  be  made  or  new  equipment  or  replacements  necessary  in  order  to  maintain  the 
classrooms  in  a  wholly  hygienic  and  sanitary  condition.  Comment  should  be 
made  also  upon  the  nature  of  the  routine  supervision  of  the  hygienic  and  sani- 
tary condition  of  the  school  building  and  classrooms.  These  reports  should  be 
made  out  on  a  standard  form  and,  when  completed,  should  go  to  the  Director 
of  the  Department  and  by  him  be  transmitted  to  the  supervising  custodian  for 
adjustment.  The  latter  should  thereupon  see  that  the  matters  complained  of 
are  adjusted,  then  report  back  to  the  Director  of  the  Department  of  Health  Super- 
vision of  School  Children. 

2.  Physical  Examination: 

Physical  examination  should  be  made  by  the  school  doctors  of  all  pupils  in 
the  schools  in  the  following  order: 

(a)  Children  entering  school  for  the  first  time. 

(6)  Children  specially  referred  by  teachers  or  nurses. 

(c)    Children  in  the  third  grade. 

(</)  Children  in  the  sixth  grade. 

It  is  realized  that  this  outline  is  a  marked  departure  from  the  present  practice,  but  unless 
the  number  of  physicians  employed  can  be  increased  sufficiently  to  warrant  such  a  course, 
no  attempt  should  be  made  to  give  the  children  a  physical  examination  each  year.  With 
the  present  staff  such  an  examination  must  be  superficial  and  of  little  value.  If  only  a 
small  appropriation  can  be  made  available,  it  should  be  devoted  entirely  to  the  children 
of  the  earlier  age  groups.  Extensive  investigations  have  shown  that  the  number  of  physical 
defects  found  in  school  children  reach  their  height  in  the  ten  to  twelve  year  period.  Exami- 
nation of  356,000  children,  with  a  tabulation  of  the  physical  defects  found,  by  type,  age 
and  sex  is  shown  on  the  "graph"  which  follows.  It  is  evident  that  the  time  to  deal  with  phy- 
sical defects  is  when  they  first  appear  or  when  they  are  increasing  in  frequency.  Until  this 
period  of  life  can  be  cared  for  in  an  adequate  manner,  it  cannot  be  considered  a  proper 
expenditure  of  public  funds  to  make  examinations  of  children  whose  defects  are  decreas- 
ing in  number,  and  on  whom  the  damage  caused  by  previous  defects  has  already  made  a 
definite  impression.  It  cannot  be  stated  too  strongly  that  the  time  when  children  need 
the  prevention,  detection  and  correction  of  physical  defects  is  in  the  very  early  age  periods, 
that  is,  under  ten  years  of  age,  and  unless  provision  can  be  made  for  making  the  present 
type  of  physical  examination  more  adequate,  the  recommendations  made  above  as  to  the 
routine  physical  examinations  should  be  carried  out. 

In  a  properly  organized  system  of  school  medical  inspection,  the  nurse's  routine 
inspection  of  all  pupils  in  the  classrooms  once  a  month  should  detect  any  cases  of  physical 
defects  that  need  attention.  This  class  of  cases  is  referred  to  under  subdivision  (b)  above, 
and  with  the  regular  physical  examination  three  times  during  the  school  life  of  the  child, 
in  addition  to  an  immediate  physical  examination  of  every  child  who  is  found  to  have  any 
physical  defect  or  who  needs  attention  in  any  way,  it  should  be  practically  impossible 


304 


Hospital  and  Health  Survey 


for  children  to  reach  the  upper  grades  in  school  life  and  still  be  found  to  have  physical 
defects  which  interfere  with  their  health  or  progress.  It  is  recommended  that  the  physical 
examination  cover  the  following  points: 

(a)   Palpation  of  cervical  glands  and  thyroid  gland. 

(6)   Thorough  inspection  of  posture,  with  palpation  of  scapulae, 

chest  and  hips,  also  testing  of  poise. 
(c)    Testing  of  hearing,  right  and  left  ears  separately,  with  watch. 

"Graph"  of  Incidence  of  Physical  Defects  in  School  Children  by  Age  Periods  and  Sex 


Age 


8-10 


10-12 


12-14 


16       Age 


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FEMALE 

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A  Program  for  Child  Health  305 


(</)  Testing  of  vision. 

(e)  Taking  of  height  and  weight. 

(/)  Examination  of  nutrition. 

(g)  Examination,  preferably  without  shoes,  for  flat  feet. 

(A)  Examination  of  heart. 

(i)  Examination  of  lungs  in  all  cases. 

Re -examinations  should  be  made  of  all  children  after  treatment  has  been 
provided  for  the  correction  of  physical  defects.  Record  should  be  made  on  the 
child's  physical  record  card  of  its  condition  at  this  time.  If  it  is  evident  that  the 
treatment  has  not  been  effective,  further  follow-up  work  should  be  carried  on 
and  no  child  should  be  finally  discharged  until  its  defect  has  received  adequate 
attention. 

Special  Examination  of  the  Heart: 

Special  examination  should  be  made  of  the  heart  of  each  child  who  has  been 
absent  on  account  of  diphtheria,  tonsilitis,  measles  or  scarlet  fever. 

3.  Health  Conferences: 

The  school  doctors  should  hold  frequent  health  conferences  with  the  chil- 
dren. They  should  give  them  individual  instruction  in  the  care  of  their  health. 
Whenever  possible,  they  should  induce  the  mothers  to  be  present  at  the  time 
the  children  are  physically  examined  so  that  conference  may  be  had  with  both 
mother  and  child. 

4.  Emergency  Treatments: 

The  medical  inspectors  should  carry  out  only  such  emergency  treatments 
as  may  be  absolutely  essential,  and  thereafter  children  so  treated  should  be 
referred  to  their  private  physicians,  hospitals  or  dispensaries  for  the  necessary 
care. 

5.  Instruction  of  Teachers: 

The  medical  inspectors  should,  by  means  of  group  conferences  and  indi- 
vidual talks,  instruct  all  teachers  of  the  classes  under  their  supervision  in  methods 
of  detecting  symptoms  and  signs  of  illness  in  children,  with  particular  reference 
to  infectious  diseases  as  well  as  the  early  symptoms  of  physical  defects  or  any 
signs  of  ill  health.  These  conferences  should  be  repeated  at  sufficiently  frequent 
intervals  so  that  there  may  be  no  doubt  as  to  the  teachers  carrying  out  the  in- 
structions they  have  received. 

6.  School  Visits: 

Each  school  under  the  supervision  of  the  medical  inspector  should  be  visited 
by  him  at  least  three  times  a  week.     At  each  visit,  in  addition  to  attending  to 


306  Hospital  and  Health  Survey 

his  other  duties,  he  should  consult  with  the  nurses  to  determine  whether  the 
matters  under  his  jurisdiction  are  being  cared  for  in  an  adequate  manner. 

(&)  Duties  of  the  School  Nurses: 

The  schools  nurses  should — 

/.  Be  relieved  at  once  of  all  clerical  duties  in  connection  with  the  physical 
examination  of  school  children.  Junior  health  workers  should  be  used  for  the 
purpose  of  recording  all  essential  data  and  assisting  the  doctors  by  doing  the 
writing  that  is  necessary. 

2.  Have  under  her  Jurisdiction  not  more  than  two  thousand  children. 

3.  Visit  each  school  under  her  supervision  each  morning  and  examine  all 
children  referred  by  the  teachers  as  suspected  cases  of  infectious  diseases, 
excluding  indicated  children  from  school  attendance. 

4.  Inspect  all  children  who  have  been  absent  from  school  three  days  or 
more  because  of  illness,  to  see  that  they  are  in  proper  condition  to  return  to 
their  classes.  If  they  have  been  absent  because  of  contagious  disease,  she  should 
see  that  they  have  the  proper  certificates  showing  that  they  are  no  longer  likely 
to  spread  infection. 

5.  Hold  school  consultations  with  parents  in  cases  where  the  children's 
physical  condition  needs  readjustment. 

6.  Have  health  conferences  with  individual  pupils  or  groups  of  pupils. 
These  conferences  should  not  be  superficial  in  character  but  should  be  distinctly 
health  talks  with  the  children,  with  careful  consideration  of  the  individual  prob- 
lems of  each  child.  Each  health  conference  should  be  followed  by  a  visit  to  the 
home,  where  the  parent  and  child  may  be  talked  with  together  and  the  child's 
home  environment  adjusted  where  necessary. 

7.  Devote  at  least  half  of  each  day  to  follow-up  visits  to  the  homes.  The 
home  environment  should  be  studied  and  readjusted  to  the  needs  of  the  child. 
Matters  of  home  ventilation,  cleanliness,  condition  of  toilets,  proper  disposal  of 
refuse  and  all  environmental  matters  likely  to  affect  the  health  of  the  child  should 
receive  careful  attention.  In  addition,  the  home  routine  and  hygiene  of  the  child 
should  be  outlined  carefully  so  that  the  mother  may  follow  it  out  in  detail. 

8.  Make  every  effort  to  see  that  the  child  receives  appropriate  treatment  in 
all  instances  where  physical  defects  exist.  Such  cases  should  be  followed  up 
carefully  and  frequent  and  sufficient  home  visits  should  be  made  to  be  sure  that 
the  child  is  receiving  proper  and  adequate  care  and  that  its  defects  have  been 
corrected,  and  that  everything  possible  is  being  done  to  prevent  the  occurrence 


A  Program  for  Child  Health  307 

of  other  physical  defects.  Cases  should  not  be  terminated  or  considered  closed 
until  every  effort  has  been  made  to  see  that  the  child  is  placed  under  proper 
conditions  and  has  received  the  essential  care. 

9.  Make  routine  inspection  of  all  children  in  their  classrooms  not  less  often 
than  once  a  month  to  discover  and  refer  to  the  doctor  any  contagious  eye  or  skin 
disease,  any  symptoms  of  illness  or  any  sign  of  physical  defect. 

10.  Consult  with  the  teachers  at  frequent  intervals  regarding  the  condition 
of  individual  pupils  and  readjustment  of  classroom  activities  and  environment 
for  the  benefit  of  the  child. 

(c)  Duties  of  Field  or  Supervising  Nurses: 

1.      The  field  nurses  should  be  increased  in  number  so   that  there  will  be 
one  to  every  ten  staff  nurses.     They  should — 

(a)  Hold  conferences  with  the  nurses  under  their  jurisdiction  at 
least  once  a  week.  Occasionally,  some  special  speaker  may  be 
asked  to  address  the  nurses.  At  these  conferences  considera- 
tion should  be  given  to  case  histories,  the  various  individual 
problems  confronting  the  nurses,  criticisms  of  the  service  or 
suggestions  for  its  improvement,  and  to  matters  pertaining  to 
the  proper  conduct  of  the  work. 

(6)  Visit  each  nurse  at  her  school  at  least  once  a  week  for  the  pur- 
pose of  conferring  with  her  upon  all  matters  pertaining  to  the 
work.  There  should  be  inspiration  and  assistance  as  well  as 
criticism  given  to  the  nurses  on  these  visits.  Routine  investi- 
gation of  records  is  not  sufficient.  The  live,  vital  and  manifest 
interest  in  the  importance  of  the  work  carried  on  by  the  nurse 
and  her  ability  to  conserve  the  health  of  the  children  should 
receive  first  consideration. 

(c)  Feel  responsible  in  every  way  for  the  conduct  of  the  work  of  the 
nurses  under  her  jurisdiction.  Because  the  efficiency  of  the 
work  will  depend  very  largely  upon  the  type  of  supervision  car- 
ried on,  field  nurses  should  be  women  of  excellent  training  and 
broad  social  vision.  They  should  have  a  genuine  liking  for 
public  health  work  and  for  children,  and  should  have  executive 
ability  and  the  power  to  inspire  others. 

(d)  Duties  of  Junior  Health  Workers: 

1.      The  number  of  junior  health  workers  should  be  increased  so  that  there 
will  be  one  for  each  nurse.      These  employes  should — 


308  Hospital  and  Health  Survey 

(a)  Assist  the  doctors  in  all  physical  examinations,  make  the  neces- 
sary records,  do  all  clerical  work  required  and  carry  on  whatever 
other  functions  may  be  indicated. 

(6)  Assist  the  nurses  in  all  their  school  duties. 

(c)  Make  home  visits  to  children  whose  families  have  already  been 
visited  by  the  nurses. 

(d)  Take  children  to  dispensaries  or  clinics  for  treatment. 

It  is  obvious  that  the  position  of  junior  health  worker  is  one  of  increasing  importance 
and  that  the  duties  cannot  be  strictly  outlined  at  the  present  time.  They  may  be  extended 
and  added  to  from  time  to  time  and  the  sphere  of  her  usefulness  greatly  increased. 

3.  Physical  Defects: 

More  emphasis  should  be  placed  upon  the  prevention  rather  than  the  correc- 
tion of  physical  defects.  In  order  to  do  this  the  following  recommendations 
are  made: 

(a)  There  should  be  greater  attention  paid  to  the  hygiene  of  the 
school  building  and  its  proper  adjustment  to  the  child's  physical 
needs. 

(6)  The  nurses  should  make  more  home  visits  and  at  such  home 
visits  should  pay  particular  attention  to  readjustment  of 
environmental  and  other  conditions  which  may  have  any  rela- 
tion to  the  production  of  physical  defects.  The  effect  of  home 
conditions  in  the  preservation  of  health  and  prevention  of 
disease  should  be  a  matter  of  careful  study  and  well-thought- 
out  attention. 

(c)  More  careful  examination  should  be  made  to  determine  the 
presence  of  physical  defects,  particularly  in  their  early  stages 
and  in  the  younger  age  groups.  This  early  detection  should  lead 
to  early  correction,  and  in  any  case  the  physical  examination 
should  offer  an  opportunity  for  the  type  of  health  instruction 
which  will  prevent  the  occurrence  of  defects  in  the  future. 

(d)  The  health  records  should  be  made  a  more  integral  part  of  the 
child's  school  life  and  should  follow  it  from  the  baby  health 
center,  through  the  pre-school  age,  school  age  and  high  school 
or  into  industry. 

(e)  The  doctor  and  nurse  should  pay  more  attention  to  individual 
health  talks  with  the  children  and  to  health  instruction  in  the 


A  Program  for  Child  Health  309 

classrooms.  The  question  whether  health  teaching  or  the  teach- 
ing of  hygiene  is  an  academic  function  must  be  given  careful 
consideration. 

4.  Clinic  Facilities: 
(a)  Dental  Clinics: 

1.  There  should  be  more  dental  clinics  and  as  rapidly  as  possible  pro- 
vision should  be  made  for  at  least  one  dental  clinic  for  each  four  schools. 
This  number  is  given  as  the  minimum  for  effective  work. 

2.  Not  only  should  the  present  methods,  which  are  based  upon  treating  chil- 
dren of  the  first  and  second  grades,  be  continued,  but  the  work  should  be  extended 
in  the  following  manner: 

(a)  An  oral  hygienist  should  be  assigned  to  each  school.  The  func- 
tion of  these  oral  hygienists  should  be  to  examine  and  thoroughly 
clean  the  teeth  of  the  children  of  the  first  and  second  grades  at 
least  once  each  term,  to  chart  out  all  dental  defects  and  refer  such 
children  to  their  family  dentists  for  proper  treatment.  If  treat- 
ment is  not  obtained,  the  children  should  be  referred  to  the 
school  dentists.  The  oral  hygienists  should  also  assist  the 
dentists  in  every  way  possible,  conduct  tooth  brush  drills  and 
give  talks  on  dental  subjects  to  the  children  in  the  classrooms. 
After  a  child  has  once  been  placed  under  the  care  of  a  dental 
hygienist,  it  should  be  required  to  report  at  least  once  each 
term  during  its  entire  school  life  for  careful  dental  inspection. 

5.  Special  Classes: 
(a)  Open  Air  Classes: 

The  relation  of  fresh  air  to  health  is  one  of  such  vast  importance  that  it  cannot  be 
considered  that  the  schools  have  done  their  full  duty  in  this  matter  simply  by  establish- 
ing open  air  classrooms.  However,  classrooms  of  this  type  do  seem  to  fill  a  certain  need 
at  the  present  time,  and  until  matters  can  be  arranged  so  that  all  classrooms  shall  have 
the  benefit  of  free  and  adequate  ventilation,  and  until  all  children  can  have  the  contin- 
uous health  supervision  which  is  now  given  to  the  children  in  the  open  air  classes,  class- 
rooms of  this  type  should  be  extended  as  rapidly  as  possible. 

There  should  be 

1.  At  least  one  open  air  classroom  in  each  school.  If  the  number  of 
children  found  to  need  this  special  kind  of  care  is  in  excess  of  the  capacity  of  the 
one  classroom,  ample  provision  should  be  made  to  care  for  all  such  children. 


310  Hospital  and  Health  Survey 

2.  Provision  for  a  special  lunch  for  all  children  in  these  open  air  classes 
such  as  is  provided  in  the  open  air  classes  already  established.  This  lunch  should 
be  a  feature  of  all  future  open  air  classrooms. 

3.  A  standard  covering  the  type  of  children  to  be  admitted  to  these  classes, 
as  follows: 

(a)  Children  exposed  to  tuberculosis  at  home,  or  in  whose  family 
there  has  been  a  recent  death  from  this  disease. 

(b)  Children  who  have  had  tuberculosis,  which  is  now  arrested  or 
cured. 

(c)  Children  suffering  from  malnutrition. 

(d)  Children  who  become  tired  easily  or  show  languor  or  fatigue 
before  the  end  of  the  day,  and  on  this  account  are  unable  to 
carry  on  their  class  work. 

(e)  Children  suffering  from  nervous  diseases,  except  chorea. 

(/)  Children  who  are  absent  frequently  because  of  colds,  bronchi- 
tis, etc. 

(g)  Children  suffering  from  cardiac  disease,  who  are  recommended 
by  their  private  physicians  as  proper  cases  for  these  classes. 

4.  Provision  for  weighing  and  measuring  the  height  of  these  children  once 
a  term  and  weighing  once  each  month.  There  should  be  in  each  room  a  class 
record  showing  the  height  and  weight  of  each  child.  This  record  should  be 
available  to  the  physician  and  nurse  at  all  times. 

No  attempt  has  been  made  to  outline  a  proper  method  of  conducting  open  air  classes . 
There  is  much  literature  on  the  subject  which  gives  in  detail  the  manner  in  which  effec- 
tive work  of  this  kind  may  be  maintained. 

(6)  Nutrition  Classes: 

Without  in  any  way  attempting  to  disparage  the  value  of  intensive  work  for  the 
correction  of  undernourishment  in  children,  it  is  obvious  that  work  of  this  type  is  too 
expensive  to  be  extended  to  all  children  in  Cleveland  who  may  be  in  need  of  such  atten- 
tion and  supervision.  The  problem  of  undernourishment,  however,  is  an  extremely  seri- 
ous one  and  no  effort  should  be  spared  to  make  every  provision  possible  for  seeing  that 
this  condition  is  prevented,  or,  if  it  occurs,  that  it  receives  proper  attention  at  the  earliest 
possible  moment.  For  these  reasons  a  system  or  organization,  possibly  less  thorough 
but  more  far-reaching,  is  suggested.  It  is  designed  to  reach  every  child  who  is  found 
to  be  undernourished. 

In  order  to  accomplish  this,  it  will  be  necessary  to  classify  all  children  as  to  their 
degree  of  nourishment  and  to  take  whatever  steps  may  be  necessary  to  see  that  their 
environment  or  personal  hygiene  is  so  adjusted  that  the  proper  balance  of  health  may  be 
restored.     The  following  recommendations  are  made  for  this  purpose: 


A  Program  for  Child  Health  311 

/.  At  the  time  of  physical  examination  each  child  should  have  its  weight 
and  height  recorded  and  its  degree  of  nourishment  classified.  Two  standard 
methods  are  recommended: 

(a)  Relative  height  and  weight  in  accordance  with  standard  tables. 
Any  child  ten  per  cent  below  the  proper  weight  for  its  height 
may  be  considered  undernourished. 

(&)  Grading  according  to  the  Dunfermline  scale.  As  it  has  been 
found  that  many  children  may  have  the  proper  relative  height 
and  weight  and  still  be  undernourished,  the  technical  ability 
of  the  doctor  may  be  drawn  upon  to  determine  whether  or  not 
any  undernourishment  exists.  For  this  purpose  the  use  of  the 
Dunfermline  scale  is  recommended. 

2.  There  should  be  in  each  classroom  a  chart  for  recording  height  each 
term  and  weight  each  month  for  each  child.  This  height  and  weight  record 
may  be  kept  by  the  teacher  or  by  some  specially  appointed  monitor  in  each  class- 
room. It  is  obvious  that  for  this  purpose  a  scale  should  be  provided  in  each 
school. 

3.  Every  matter  pertaining  to  school  life,  instruction,  sanitation  and 
hygiene,  which  influences  the  health  of  the  child  should  be  adjusted.  This  is 
particularly  necessary  with  regard  to  provision  for  proper  ventilation. 

4.  Every  undernourished  child  should  receive  individual  health  instruc- 
tion from  the  doctor  or  nurse  in  the  school,  and  its  school  life  should  be  adjusted 
to  meet  its  particular  needs. 

5.  Home  visits  should  be  made  to  each  case  of  undernourishment.  Mat- 
ters pertaining  to  hygiene  and  sanitation  of  the  home,  proper  ventilation,  food 
and  adjustment  of  hours  of  sleep,  study  and  play  are  important  points  to  be 
considered,  with  provision  of  sufficient  rest  and  absence  of  excitement. 

6.  In  the  work  of  health  education  in  the  schools,  particular  attention 
should  be  paid  to  the  importance  of  health  games,  especially  for  the  younger 
children.  The  type  of  work  carried  on  by  the  Child  Health  Organization  is  par- 
ticularly recommended. 

6.  School  Dispensaries: 

The  name  of  these  dispensaries  should  be  changed  to  something  more  in- 
dicative of  their  real  function.  "Health  Office"  is  suggested  as  more  closely 
describing  the  service  provided  there.  While  it  may  be  a  distincly  humani- 
tarian effort  to  provide  treatment  in  the  schools  for  the  children,  it  cannot  be 
considered  part  of  a  well-conducted  system  of  school  health  supervision.  Cor- 
rective work  of  this  nature  does  not  belong  in  the  schools  but  is  essentially  the 
function  of  dispensaries  conducted  under  other  authority  and  organized  for  that 


312  Hospital  and  Health  Survey 

purpose.  The  full  time  and  efforts  of  the  medical  inspectors  in  the  schools 
should  be  given  to  their  proper  function  of  prevention  of  disease  and  ill  health, 
and  the  diagnosis  of  abnormal  physical  conditions  in  the  school  children.  As 
far  as  emergency  treatment  is  concerned,  the  doctor  or  nurse  should  give  such 
care  where  it  is  necessary,  but  in  every  instance  they  should  refer  the  child  for 
further  treatment  to  the  private  physician,  hospital  or  dispensary.  In  other 
words,  the  school  dispensaries  should  discontinue  the  function  which  their 
name  implies.  The  school  building  is  not  a  place  where  sick  children  should 
be  treated,  but  a  place  where  children's  health  should  be  conserved  and  ill  health 
prevented.  Work  of  a  corrective  nature  should  be  carried  only  as  it  may  be 
necessary  for  diagnostic  purposes  or  for  first  aid  or  emergency  treatment.  The 
only  exception  to  be  made  to  this  rule  is  in  cases  of  contagious  eye  and  skin  dis- 
eases, where  it  is  difficult  or  impossible  to  obtain  treatment  elsewhere  and  still 
have  the  child  remain  in  attendance  at  school. 

7.  Records: 

The  child's  health  record  should  be  continuous  and  reach  from  the  health 
center,  through  the  pre-school  age,  the  school  age,  into  the  junior  high  school 
or  high  school  or  follow  the  child  into  industry.  In  the  absence  of  a  continu- 
ous pre-school  health  record,  a  beginning  should  be  made  as  soon  as  the  child 
enters  school.  In  order  that  such  a  health  record  may  be  made  effective  it  is 
recommended  that 

(a)  The  health  record  should  appear  on  the  same  card  as  the  school 
record  and  should  be  brought  by  the  child  to  the  doctor  each 
time  it  is  physically  examined.  On  it  should  be  noted  all  ob- 
servations made  by  the  school  doctor,  the  school  nurse  or  the 
teacher  regarding  the  health  of  the  child,  and  the  results  of 
treatment  obtained  for  any  physical  defects. 

(6)  During  the  time  the  child  is  in  school  the  record  should  be  the 
property  of  the  school  and  should  be  filed  in  the  office  of  the 
principal  or  clerk  or  in  the  individual  classrooms.  They  should 
be  available  to  the  doctor  or  nurse  at  any  time  but  should  not 
be  taken  from  the  classrooms. 

(c)  Criticism  of  the  present  form  of  health  record  would  seem  to 
lie  not  in  the  information  it  asks  for  but  rather  in  the  negligence 
that  has  been  shown  in  failing  to  keep  these  records  up  to  date. 

Physical  Training 

Recommendations  will  not  be  made  with  regard  to  the  work  of  physical  training  but 
rather  to  the  recognition  of  much  of  this  work  as  an  integral  part  of  the  health  supervision 
of  school  children  and  its  relation  thereto.  As  at  the  present  time  this  work  is  carried  out 
mainly  in  the  junior  high  schools  and  the  high  schools,  it  is  recommended 


A  Program  for  Child  Health  313 

/.  That  the  Department  of  Physical  Training  should  be  an  integral 
part  of  the  Department  of  Health  Supervision  of  School  Children. 
The  methods  of  physical  examination  should  be  standardized 
and  made  to  include  all  children  in  the  junior  high  schools  and 
the  high  schools.  If  this  department  is  to  participate  in  the 
work  of  teaching  hygiene,  it  should  follow  the  standardized  out- 
line which  will  be  discussed  under  the  heading  of  "Health  Edu- 
cation," and  this  work  should  be  continuous  with  and  part  of 
the  entire  program  for  the  health  education  of  the  children. 

2.  That  every  child  in  the  junior  high  schools  and  the  high  schools 
take  with  it  its  school  record  from  the  elementary  schools  and 
that  such  health  record  be  available  for  the  purposes  of  the  De- 
partment of  Physical  Training. 

3.  That  the  physical  examinations  carried  on  by  the  Department 
of  Physical  Training  be  thorough  and  follow  the  same  routine 
as  has  been  outlined  for  the  physical  examination  of  children  in 
the  elementary  schools. 

4.  That  classes  for  the  correction  of  bad  habits  of  posture  be  estab- 
lished as  part  of  the  work  of  the  Department  of  Physical  Training. 

Health  Education 

Organized,  consistent  education  with  relation  to  all  the  factors  which  maintain  sound 
health  in  the  individual  should  be  carried  on  throughout  the  entire  school  life  of  each 
child.  A  certain  amount  of  health  care  can  be  enforced  from  without  but  the  most  im- 
portant, fundamental  provision  for  community  health  in  the  future  lies  in  each  child's 
gaining  and  applying  the  knowledge  which  is  essential  for  the  individual  maintenance  of 
personal  health  and  the  extension  of  all  community  forces  for  the  purpose  of  promoting 
the  health  of  the  people  as  a  whole.  Health  education  of  all  children  may  be  considered 
as  the  most  important  part  of  any  program  of  health  supervision.  In  order  that  such  a 
program  may  be  available  for  the  children  in  the  schools  of  Cleveanld,  it  is  recommended 
that: 

/.  Health  education  be  considered  a  function  of  the  teaching  staff. 
As  it  is,  however,  a  matter  connected  so  closely  with  health  mat- 
ters, a  committee  should  be  appointed,  advisory  to  the  Director  of 
Child  Health,  representing  all  phases  of  the  health  program, 
and  this  committee  should  work  out  a  complete  plan  of  health 
education  throughout  the  school  system,  coordinating  the 
work  of  the  several  departments  in  this  regard. 

2.  A  syllabus  be  prepared  for  instruction  in  health  and  personal 
hygiene,  for  use  in  different  grades  of  the  public  schools,  and  that 
another  syllabus  be  prepared  for  use  in  the  high  schools  and 
junior  high  schools.      These  syllabi  should  contain  specific  in' 


314  Hospital  and  Health  Survey 

struction  in  the  causes  and  methods  of  prevention  of  disease. 
The  instruction  should  not  be  of  an  academic  nature  but  of  a 
type  which  makes  a  direct  appeal  for  the  child's  cooperation. 
In  other  words,  child) en  are  not  interested  in  health  for  health's 
sake.  They  must  be  taught  the  value  of  health  and  the  way  to 
attain  it.  In  this  way  their  active  and  interested  cooperation 
may  be  enlisted.  Such  syllabi,  therefore,  in  addition  to 
teaching,  might  readily  give  directions  for  a  detailed  health 
program  covering  a  full  day  in  the  life  of  a  child  at  different  ages. 

3.  The  program  should  make  definite  provision  in  the  high  school 
curriculum  for  regular  courses  to  cover  the  main  points  of  per- 
sonal hygiene,  physiology  and  sanitation,  and  should  provide  for 
proper  correlation  of  other  subjects,  such  as  botany,  cooking, 
chemistry  and  social  problems. 

4.  The  course  on  health  education  should  be  compulsory  and  not 
elective  in  the  schools  of  all  grades. 

5.  A  syllabus  should  include  a  course  of  instruction  on  the  causes 
and  prevention  of  infectious  diseases. 

6.  A  definite  schedule  should  be  outlined  and  maintained  for  health 
talks  to  groups  of  children,  such  talks  to  be  given  by  the  doctors 
and  nurses  of  the  medical  inspection  staff. 

7 .  Individual  health  talks  should  be  given  to  the  children  by  the 
doctors  and  nurses  of  the  medical  inspection  staff.  These  indi- 
vidual health  conferences  have  already  been  referred  to  and 
should  constitute  part  of  the  work  connected  with  the  physical 
examination  of  each  child. 

8.  Health  talks  to  the  teachers  should  be  given  from  time  to  time. 
The  services  of  various  specialists  should  be  obtained  for  this 
purpose  and  talks  should  be  on  subjects  connected  with  health 
and  hygiene,  with  particular  reference  to  their  application  to 
the  health  of  childhood.  Such  talks  might  well  be  accompanied 
by  the  distribution  of  appropriate  literature  on  health  topics,  to 
be  written  and  published  by  the  Division  of  Health. 

9.  The  Board  of  Education  should  accept  the  services  of  the  Red 
Cross  Teaching  Center  to  carry  on  this  work  until  such  time  as 
appropriations  can  be  made  for  the  purpose. 

Examination  of  Teachers. 

(a)  Teachers  should  receive  a  physical  examination  on  entrance  into 
the  service  and  each  year  thereafter.  This  work  might  be  done 
by  the  medical  staff  of  the  school  medical  inspection  service. 


A  Program  for  Child  Health  315 

(6)  The  results  of  these  physical  examinations  should  be  available 
to  the  respective  teachers  and  should  be  used  by  the  Board  of 
Education  as  a  basis  for  proper  assignment  of  teachers  to  special 
duties.  Measures  by  which  these  physical  examinations  can 
be  made  of  practical  value  will  readily  suggest  themselves;  for 
instance,  teachers  who  are  anemic,  undernourished  or  who  have 
a  tubercular  tendency  should  be  assigned  to  teach  in  the  open 
air  classes  so  that  their  health  may  be  benefited  thereby. 

Sanitation  and  Hygiene  of  School  Buildings  and  Classrooms. 

1.  Administration: 

There  should  be  better  cooperation  beween  the  Department  of  Buildings  and  the 
Department  of  School  Medical  Inspection  The  plan  of  organization  already  suggested 
would  place  both  these  departments  under  the  same  authority.  The  Deparment  of 
Buildings  should  be  responsible  for  the  sanitation,  hygiene  and  healthful  maintenance  of 
the  schools  and  classrooms.  This  work  should  be  its  primary  duty,  and  while  it  should 
act  upon  complaints,  it  should  be  the  purpose  of  the  department  to  initiate  the  necessary 
methods  by  which  proper  sanitation  may  be  maintained. 

Specifically,  the  duties  of  the  custodians  of  the  schools  should  be  as  follows: 

(a)  To  receive  reports  of  sanitary  surveys,  make  proper  and  detailed 
investigation  of  all  matters  found  to  need  attention,  correct  all 
wrong  conditions  so  far  as  that  may  be  possible,  and  where  cor- 
rection by  individual  effort  is  not  possible,  refer  the  matter  to 
the  proper  authorities.  After  completion  of  these  investiga- 
tions and  correction  of  wrong  conditions,  the  custodians  should 
report  back  the  results  of  their  inspections,  and  the  action  that 
has  been  taken.  These  reports  should  be  forwarded  on  a  special 
blank,  through  the  official  channels,  to  the  Director  of  the  De- 
partment of  School  Health  Supervision. 

(6)  To  carry  on  a  regular  weekly  inspection  of  the  building  and 
classrooms.  This  inspection  should  not  be  perfunctory  but 
should  follow  standardized  lines  and  should  include  inspection  of 
all  features  of  the  school  buildings  and  classrooms  which  may 
affect  the  health  of  the  children.  Any  condition  which  is  found 
to  be  below  standard  should  receive  immediate  attention,  with- 
out waiting  for  a  specific  complaint. 

(c)  To  receive  and  act  immediately  upon  all  complaints  made  by 
teachers,  doctors  or  nurses  and  to  report  back  to  the  proper 
authorities  what  action  has  been  taken  with  regard  to  the 
complaint. 


316  Hospital  axd  Health  Survey 


(d)  To  hold  themselves  absolutely  responsible  for  seeing  that  the 
rules  and  regulations  of  the  Board  of  Education  in  regard  to 
ventilation,  temperature,  seating,  drinking  facilities,  toilets, 
sweeping  and  dusting,  provision  of  soap  and  towels,  are  carried 
out  in  an  orderly  and  systematic  manner.  If  this  is  done  as  a 
result  of  weekly  inspection,  there  would  be  little  opportunity 
for  complaint  as  to  maladjustments  or  infractions  of  the  rules. 

2.  School  Hygiene: 

Special  consideration  should  be  given  to  the  detailed  features  of  school  hygiene,  as 
follows: 

(a)  Ventilation: 

Proper  ventilation  of  classrooms  is  the  most  important  single  feature  of  school  hygiene. 

A  sufficient  supply  of  fresh  air  will  prevent  the  spread  of  infectious  disease,  prevent  physi- 
cal defects,  increase  resistance  to  disease  and  lay  the  foundation  for  sound  health  not 
only  during  childhood  but  in  adult  life. 

It  is  recommended  that: 

/.  Steps  be  taken 

(a)  To  amend  the  state  law  so  thai  it  will  be  possible  to 
discontinue  all  methods  of  artificial  ventilation  of 
classrooms,  except  in  those  cases  where  open  window 
ventilation  is  impossible. 

(6)  To  provide  for  the  necessary  methods  of  open  window 
ventilation  by  the  proper  types  of  windows  and  window 
boards. 

2.  Open  window  classrooms  be  maintained  at  a  temperature  be- 
tween sixty  and  sixty-eight  degrees  and  that  in  all  instances  where 
the  temperature  is  below  sixty  degrees  the  necessary  additional 
wraps  or  blankets  be  provided  for  the  teachers  and  children. 

(6)   Temperature: 

High  temperatures  in  classrooms  are  found  to  be  extremely  prejudical  to  good  health. 

It  is   recommended  that: 

/.  A  thermometer  be  placed  in  each  classroom  and  that  the  tem- 
perature of  the  classroom  as  registered  by  this  thermometer  be 
read  twice  each  day  by  the  teacher  and  recorded  in  a  book  kept 
for  that  purpose. 

2.  The  temperature  in  any  classroom  should  not  be  allowed  to  re- 
main above  sixty -eight  degrees  Fahrenheit.      When  a   tempera- 


A  Program  for  Child  Health  317 

ture  above  that  point  is  registered  the  custodian  should  be  noti- 
fied at  once  so  that  he  may  take  whatever  action  is  necessary  to 
restore  the  proper  temperature. 

(c)  Seating: 

Postural  defects  are  so  definitely  caused  by  improper  seating  arrangements  in  class- 
rooms that  it  is  of  the  utmost  importance  to  outline  some  plan  whereby  seats  and  desks 
may  be  adjusted  to  suit  the  individual  children.  The  present  system  of  "shifting"  classes 
renders  it  extremely  difficult  to  outline  any  method  by  which  these  adjustments  may  be 
made,  as  the  same  child  may  not  occupy  any  given  seat  for  two  days  or  even  two  hours 
in  succession.  If  it  is  impossible  to  adjust  the  curriculum  in  a  way  that  will  help  to  solve 
this  problem,  and  since  the  rooms  used  by  these  "shifting"  classes  are  likely  to  be  used 
by  children  ranging  in  age  from  six  to  fifteen  years,  it  is  recommended 

/.  That  rooms  used  by  such  classes  be  divided  into  group  units,  each 
such  unit  to  be  occupied  by  children  of  a  given  age  group.  Once 
each  term  the  seats  in  these  classes  should  be  adjusted  for  the 
average  age  groups  that  will  occupy  the  rooms.  In  this  way  the 
children  will  use  seats  and  desks  that  are  approximately  suited 
to  their  ages,  even  if  not  entirely  so. 

2.  That  in  cases  where  the  children  can  continue  to  occupy  the  same 
classroom  throughout  the  entire  term,  the  seats  be  adjusted  to 
their  individual  requirements.  It  is  suggested  that  the  following 
standard  be  used:  seat  to  be  two-sevenths  the  height  of  the  child, 
desk  three-sevenths,  top  of  desk  to  extend  over  the  front  edge 
of  the  chair  for  a  distance  of  at  least  two  inches. 

(d)  Toilets: 

The  standard  required  by  the  state  law  governing  the  number  of  toilets  to 
be  provided  in  school  buildings  is  adequate  and  provision  should  be  made  for  its 
enforcement  in  every  instance  where  the  number  at  present  provided  is  below 
that  required.  The  custodians  should  be  held  responsible  for  the  condition  of 
the  toilets  and  this  matter  should  not  be  left  to  the  school  doctors  and  nurses. 
The  custodians  should  be  required  to  carry  out  in  detail  the  provisions  of  Rule 
VIII  of  the  Rules  and  Regulations  for  the  Government  of  Custodians.  Such 
an  inspection  and  supervision,  if  carried  out  in  accordance  with  these  rules  and 
regulations,  would  be  all  that  is  necessary  to  keep  the  toilets  in  proper  and  sani- 
tary condition.  Whatever  criticism  may  be  made  of  their  condition  at  the  pres- 
ent time  must  be  based  upon  the  fact  that  the  rules  are  ignored,  not  that  they 
do  not  contain  the  proper  provisions  for  the  subject. 

(e)  Drinking  Facilities: 

1.     The  proper  number  of  drinking  fountains  should  be  provided  in  each 
school  building. 


318  Hospital  and  Health  Survey 

2.  The  drinking  fountains  used  should  be  of  a  type  which  makes  it  impos- 
sible for  the  child  to  touch  the  nozzle  with  the  mouth  while  in  the  act  of  drinking. 

3.  Sufficient  water  pressure  should  be  maintained  at  all  times  so  that  the 
flow  of  water  from  the  nozzle  will  be  of  sufficient  force  to  carry  the  stream 
not  less  than  two  inches  in  an  upright  direction. 

4.  As  fast  as  new  drinking  fountains  can  be  installed,  it  is  recommended 
that  the  type  be  used  where  the  stream  of  water  from  which  the  person  drinks 
is  caused  by  the  confluence  of  numerous  other  streams  of  water.  Such  a  type 
has  no  part  that  can  be  touched  by  the  mouth  of  the  child,  therefore  it  cannot 
in  any  way  be  considered  a  possible  source  of  transmission  of  infectious  diseases. 

5.  Drinking  fountains  should  be  inspected  daily  by  the  custodians  and  at 
all  times  should  be  kept  in  a  workable  and  cleanly  condition. 

(/)  Soap  and  Towels: 

1.  The  schools  should  be  provided  at  all  times  with  facilities  so  that  the 
pupils  may  wash  their  hands.  Rule  X  of  the  Rules  and  Regulations  for  the 
Government  of  Custodians  should  be  adhered  to. 

2.  The  children  should  be  instructed  by  the  teachers,  doctors  and  nurses 
to  wash  their  hands  each  time  after  coming  from  the  toilet  and  before  each  meal. 
It  should  be  the  duty  of  the  teachers  to  question  the  children  as  often  as  may  be 
necessary  in  order  to  see  that  this  practice  is  carried  out. 

(g)  Sweeping  and  Dusting: 

As  rapidy  as  possible,  in  all  new  buildings  constructed,  provision  should 
be  made  for  vacuum  cleaning  systems,  and  all  sweeping  and  dusting  should  be 
done  by  that  method.  Rules  and  Regulations  for  the  Government  of  Custodians 
with  regard  to  sweeping  and  dusting  and  other  cleaning  of  the  school  building 
and  its  equipment  should  be  adhered  to  in  every  particular.  These  rules  are 
excellent  and,  if  applied,  would  furnish  all  necessary  protection  to  the  health 
of  the  children.  When  neglected  and  not  complied  with,  however,  this  neglect 
is  a  menace  and  immediate  steps  should  be  taken  to  see  that  provision  is  made 
for  proper  enforcement  of  the  regulations. 

Issuance  of  Work  Certificates 

Recommendations  for  changes  in  the  law  controlling  the  issuance  of 
work  certificates  and  in  the  methods  of  enforcing  the  law,  are  made  in  the 
report  on  "Children  in  Industry,"  to  which  reference  is  made,  Part  VII. 


A  Program  for  Child  Health  319 

Conclusions 

The  only  adequate  test  as  to  the  success  of  any  efforts  for  child  hygiene 
lie  not  in  the  statistics  of  immediate  achievement  but  in  the  results  to  be 
seen  in  later  years. 

The  effectiveness  of  prenatal  work  must  be  measured,  not  by  the  number 
of  mothers  who  reach  their  period  of  confinement  in  good  health  but  in 
the  number  of  babies  who  die  in  the  early  months. of  life  from  congenital 
defects  and  diseases,  and  the  number  who  survive  in  good  health. 

Proper  maternity  service  must  be  measured  not  only  by  the  reduction 
in  the  maternal  mortality  rate  but  by  the  future  health  of  the  mother  and 
child. 

Efforts  for  the  care  of  babies  cannot  be  measured  by  consideration  of 
the  infant  death  rate  alone.  It  is  not  enough  merely  to  keep  a  baby  alive 
during  its  first  year.  The  true  test  of  the  efficiency  of  this  work  is  the  knowl- 
edge that  these  children  survive  the  perils  of  early  childhood  and  are  alive 
and  well  at  a  later  period  than  infancy.  The  reduction  in  the  death  rate 
under  five  years  of  age  is  the  only  sure  index  of  the  worth  of  the  care  given 
under  one  year  of  age. 

The  care  of  the  child  during  the  pre-school  age  (from  two  to  five  years) 
does  not  finally  show  itself  in  the  reduction  of  the  sickness  or  death  rate 
during  those  ages.  The  true  test  comes  later.  Are  these  children  in  sound 
health  when  they  enter  school?  Have  their  physical  defects  been  prevented 
or  corrected  in  their  incipiency? 

Efficient  school  health  supervision  is  reflected  not  in  the  number  of 
defects  corrected  or  the  number  of  physical  examinations  made.  If  the 
health  work  for  children  has  been  adequate  previously,  and  they  come  to 
school  in  good  physical  condition,  our  efforts  must  be  directed  towards  see- 
ing that  neither  the  school  nor  the  home  life  at  this  period  interferes  with 
their  future  development,  and  that  the  conditions  under  which  they  live, 
whether  in  the  school  or  at  home,  are  in  accordance  with  the  best  that  modern 
hygiene  and  sanitation  can  offer.  Retardation  and  failure  to  pass  examina- 
tions for  physical  reasons  are  an  indictment  of  the  health  work  so  far  per- 
formed, but  the  real  object  is  not  to  achieve  this  result.  It  is  to  safeguard 
the  child,  to  keep  it  in  good  health  and  to  teach  it  the  principles  and  practice 
of  those  measures  which  will  assure  good  health  not  only  to  the  child  but 
to  the  whole  community  in  which  it  lives. 

The  test  of  all  health  work  for  children  lies,  then,  in  the  prevention  of 
disease  during  infancy  and  childhood,  in  the  building  up  of  a  robust,  well- 
developed  and  physically  and  mentally  sound  boy  or  girl,  one  who  is  capable 
not  only  of  withstanding  the  hazards  of  disease  during  child  life  but  who 
understands  the  rules  of  health  and  so  applies  them  that  soundness  of  body 
and  freedom  from  disease  is  assured  during  all  of  its  adult  life.  This  is  the 
goal  and  the  ultimate  object  to  be  attained  in  our  work  for  children.    After 


320  Hospital  and  Health  Survey 

adolescence  they  can  use  for  themselves  the  information  they  have  acquired; 
during  childhood  we  have  the  opportunity  to  see  that  the  foundation  for 
this  future  good  health  is  laid  securely.  It  is  neither  a  difficult  nor  a  costly 
matter  to  assure  to  each  child  in  each  community  its  full  heritage  of  sound 
health.  Children  are  the  only  real  wealth  the  nation  possesses,  and  it  is 
our  privilege  as  well  as  our  duty  to  care  for  our  children  and  to  give  them 
with  a  free  hand  those  opportunities  for  health  which  they  are  unable  to 
obtain  for  themselves. 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

X.     Hospitals  and  Dispensaries. 

XL     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 

These  parts  may  be  obtained,  at  a  cost  of  50c  each,  from 

THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Premier  Press 

Clevenlad,  O 


Tuberculosi 


Part  Four 


Cleveland    Hospital    and 
Health    Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -   Ohio 


Pref 


reiace 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director 

and  the  following  collaborators : 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

I.     The  Story  in  Brief.  Page 

Cleveland's  Equipment  for  Fighting  Tuberculosis 331 

Past  Accomplishments 331 

Immediate  Needs 332 

Recommendations 334 

II.     Objects  and  Methods... _ 336 

III.  The  Statistical  Record  of  Tuberculosis  in  Cleveland. 

Population  and  General  Mortality. ..... 338 

Tuberculosis  Mortality 339 

Tuberculosis  Morbidity 343 

IV.  General  Provisions  for  Attack  and  Defense  Against  Tuberculosis. 

Education 1. 346 

Legislation _ 346 

General  Sanitation.... _ 347 

V.     Special  Provisions  for  Fighting  Tuberculosis. 

Division  of  Health 355 

Institutional  Provisions _ 357 

Other  Organization  Community  Measures _ 362 

VI.     A  Summary  of  Activities  and  Equipment. 

The  Prevention  of  Tuberculosis... 364 

The  Detection  of  Tuberculosis... : 365 

The  Treatment  of  Tuberculosis 366 

Follow-up  Methods 367 

Education  Against  Tuberculosis.... _ 368 

Tuberculosis  Research  and  Teaching... 368 

Anti-Tuberculosis  Organization *„.  368 

VII.     Recommendations.... 370 

Appendix 

Tables 378 


Tuberculosis 

By  Donald  B.  Armstrong,  M.  D. 
I. 

The  Story  in  Brief 
CLEVELAND'S  EQUIPMENT  FOR  FIGHTING  TUBERCULOSIS 

TUBERCULOSIS  is  in  large  measure  a  preventable  and  curable  disease, 
yet  each  year  between  ten  and  twelve  hundred  Cleveland  citizens  die  from 
this  cause  alone.  Nearly  six  thousand  known  cases  are  constantly 
afflicted  with  this  disease,  a  social  handicap  and  economic  burden  to  them- 
selves, their  families  and  the  city. 

Cleveland  has  been,  in  comparison  with  other  American  cities,  by  no 
means  backward  in  the  development  of  machinery  for  defense  against  this 
''captain  of  the  men  of  death."     Public  and  private  interests  have  provided: 

1.  A  Bureau  of  Tuberculosis  in  the  Division  of  Health  (at  present  without 
a  head). 

2.  Seven  Division  of  Health  tuberculosis  clinics  in  the  Health  Centers,  dis- 
tributed throughout  the  city. 

3.  A  staff  of  eighty  or  more  general  public  health  nurses  in  the  Division  of 
Health,  devoting  considerable  time  to  finding  and  supervising  tuberculosis 
patients. 

4.  Municipal  and  private  institutions,  providing  approximately  500  beds  for 
the  care  of  early  and  advanced,  childhood  and  adult,  pulmonary  and  non- 
pulmonary  cases  of  tuberculosis. 

5.  An  Anti-Tuberculosis  League,  responsible  for  the  initiation  of  many  of  the 
excellent  anti-tuberculosis  provisions  in  the  past,  and  alive  to  its  present 
obligations  for  educational  and  other  activities  aimed  at  the  control  of 

this  disease. 

i 

6.  A  background  of  legislative  provisions,  a  system  of  general  sanitary  and 
milk  control,  organization  for  infant  welfare  and  school  health  work,  for 
material  relief,  guidance,  etc. — all  important  in  the  war  on  consumption, 
and  all  comparing  favorably  in  theory  and  practice  with  those  provided 
in  the  average  American  city. 

PAST  ACCOMPLISHMENTS 

With  this  machinery  for  tuberculosis  control,  Cleveland's  accomplish- 
ments are  of  no  mean  order.  Their  appraisal  is  of  great  significance,  for  if 
we  are  to  estimate  the  potential  possibilities  of  a  community,  we  must  know 
its  "past  performances."  From  this  point  of  view  the  outlook  is  encour- 
aging. Among  the  mileposts  of  progress  in  Cleveland's  fight  on  the  Great 
White  Plague  are: 


332  Hospital  axd  Health  Survey 


1.  A  courageous  pioneer  development  of  a  health  center  system,  coupled 
with  generalized  nursing,  an  experiment  and  demonstration  in  social 
machinery  for  disease  control  of  national  value. 

2.  A  gradual  development  of  tuberculosis  clinic  attendance  of  thousands 
annually,  totaling  over  sixty-one  thousand  patients  for  the  period  1914-18. 

3.  The  registration  of  4.7  active  tuberculosis  cases  in  1918  for  every  annual 
death,  a  ratio  that  compares  favorably  with  the  usual  American  municipal 
and  state  registration  of  3  or  4  cases  to  a  death. 

4.  The  establishment  of  the  Warrensville  Sanatorium,  most  noteworthy 
among  Cleveland's  institutional  provisions  for  tuberculosis,  in  many 
respects  a  model  institution  both  in  equipment  and  management. 

5.  An  encouraging  reduction,  as  observed  in  many  other  communities,  of  the      / 
annual  tuberculosis  death  rate,  a  fall  from  225  per  hundred  thousand  of 
the  population  during  1865-69  to  145  per  hundred  thousand  for  the  period 
1913-17. 

IMMEDIATE  NEEDS 

In  spite  of  these  accomplishments,  much  remains  to  be  done  if  the  disease 
is  to  be  reduced  to  a  minimum— measures  that  do  not  await  fresh  discov- 
eries in  disease  control,  but  that  depend  on  the  use  of  known  and  demon- 
strated means  for  tuberculosis  elimination.  If  we  measure  Cleveland  against 
ideal  standards,  it  is  because  of  our  faith  in  the  city's  ability  to  approximate 
these  standards: 

TUBERCULOSIS  IS  A  COMMUNICABLE,   WIDESPREAD  INFECTION,  AN 
INFECTION  THAT  CAN  BE  REDUCED  BY: 

Education  in  Personal  Hygiene. 

Very  little  is  being  done  in  this  direction  at  present  in  Cleveland,  either 
to  suppress  disease  transmission,  as  through  the  elimination  of  common  uten- 
sils, or  to  increase  general  resistance,  as  through  the  promotion  of  more 
adequate  milk  consumption  by  children. 

Control  of  Dangerous  Infectious  Cases. 

Cleveland  has  the  legislation  necessary  for  the  segregation  of  such  cases, 
but  employs  it  rarely. 

The  Prevention  of  Dangerous  Spitting. 

In  1917  there  were  41  convictions  for  violation  of  the  anti-spitting  ordi- 
nance, in  1918  there  were  7,  in  1919  none,  in  1920  none  up  to  June  1st. 

The  Sanitation  of  Milk  Supplies. 

Cleveland  has  a  milk  supply  of  fair  quality,  but  reliance  upon  country 
milk  inspection  and  upon  pasteurization,  instead  of  actually  testing  the  bac- 
teriological purity  of  the  product  as  delivered  to  the  consumer,  has  allowed  a 


Tuberculosis  333 


false  sense  of  security  to  develop.  About  half  of  the  samples  of  bottle  milk  as 
delivered  were  found  to  be  so  heavily  polluted  as  to  be  unsafe  for  use.  The 
milk  standards  required  by  law  are  adequate  but  they  are  not  consistently  or 
constantly  enforced. 

Adequate  Housing  Conditions. 

Cleveland  faces  a  serious  housing  problem,  insistently  demanding  radical 
treatment  if  tuberculosis  and  other  diseases  are  to  be  controlled.  Housing  con- 
ditions, tolerated  by  the  public  authorities  in  violation  of  every  law  of  sanitary 
safety  and  building  construction  and  maintenance,  abound  in  the  congested 
areas  where  the  incidence  and  death  rate  from  tuberculosis  are  the  highest. 


TUBERCULOSIS  IS  A  PREVALENT  DISEASE,   TO  BE  REDUCED  IN  ITS 
ACTIVE  AND  ADVANCED  FORMS  B  Y: 

The  Reduction  of  Economic  Strain. 

i 

By  the  elimination,  so  far  as  may  be  possible,  of  excessive  fatigue,  long 
working  hours,  time  lost  through  inadequate  transportation  facilities.  By 
the  provision  of  opportunities  for  healthful  recreation  for  working  people. 
By  the  development  of  facilities  for  purchase  of  food  and  clothing  at  minimum 
cost,  through  company  or  cooperative  stores.  By  the  training  of  girls  in 
domestic  economy  and  the  art  of  buying  and  cooking  food. 

By  the  development  of  adequate  industrial  health  services.  Employers 
and  employes  must  come  to  realize  that  their  common  interest  in  the  health 
of  industrial  personnel  can  best  be  served  through  the  institution  of  physical 
examinations  under  conditions  mutually  helpful. 

There  has  been  in  Cleveland  notable  progress  in  the  field  of  industrial 
hygiene,  yet  the  amount  of  tuberculosis  which  has  been  found  through  the 
examination  of  employes  or  applicants  for  employment  in  the  industries  of 
Cleveland  is  negligible.  It  has  been  overlooked,  either  because  examinations 
have  been  made  too  casually  or  because  they  have  been  made  by  physicians 
very  ill  equipped  to  examine  for  pulmonary  disease. 

The  Detection  of  Early  Cases. 

At  present  50  per  cent  of  the  cases  discovered  are  advanced.  This 
should  be  reduced  at  least  to  25  per  cent  through  the  training  of  clinic  and 
general  physicians  in  the  detection  of  early  signs  of  disease,  and  through  the 
help  of  expert  advisory  consultation  services  for  the  diagnosis  of  difficult  or 
doubtful  cases. 

At  present  Cleveland  is  registering  about  four  and  a  half  cases  for  every 
annual  death.  The  ratio  of  active  cases  to  deaths,  if  all  were  discovered, 
would  probably  be  nine  to  one  rather  than  four  and  a  half  to  one. 

More  Adequate  Provision  for  Institutional  Treatment. 

Cleveland  now  has  one  hospital  bed  for  tuberculosis  patients  for  every 
two    deaths    from    tuberculosis    annually.     The    experience    in    New    York, 


334  Hospital  and  Health  Survey 


Massachusetts,  and  elsewhere,  indicates  a  minimum  requirement  of  one  bed 
for  each  death  from  tuberculosis  per  annum. 

More  Adequate  Nursing  Provision  for  Home  Cases. 

Cleveland  now  has  one  public  health  nurse  for  approximately  every  six 
thousand  people.  The  minimum  standard,  for  generalized  public  health 
nursing  demands  at  least  one  nurse  for  every  three  thousand  of  the  popula- 
tion, if  tuberculosis  is  not  to  be  neglected.  By  generalized  public  health 
nursing  is  meant  the  system  by  which  only  one  nurse  works  in  a  given  dis- 
trict, doing  there  all  kinds  of  nursing  and  instruction  in  health. 

More  Effective  Institutional  Treatment. 

At  present  44  per  cent  of  the  male  patients  at  Warrensville  leave  "un- 
improved." The  potential  effectiveness  of  the  city's  equipment  will  continue 
to  be  in  great  measure  wasted  unless  this  percentage  is  reduced  through 
social  and  educational  devices,  more  effective  "follow-up,"  etc. 

Prompt  Reporting  Upon  Diagnosis. 

At  present  from  20  to  30  per  cent  of  the  cases  are  not  reported  until 
death. 


RECOMMENDATIONS 

To  meet  these  deficiencies  in  the  Cleveland  tuberculosis  program,  symp- 
tomatic as  indeed  they  are  of  conditions  generally  elsewhere,  certain  specific 
suggestions  are  presented.  If  ways  can  be  found  for  their  adoption  it  is 
confidently  believed  that  Cleveland  will  soon  deserve  and  receive  universal 
appreciation  as  the  city  that  fought  tuberculosis  to  a  finish. 

PREVENT  MORE  INFECTION 

1.  By  an  educational  campaign  in  the  schools,  by  agents  of  the  Division  of 
Health,  through  the  Anti-Tuberculosis  League,  on  the  dangers  of  in- 
fection, on  personal  hygiene,  on  food  hygiene,  and  in  health  habits  which 
may  increase  resistance,  etc. 

2.  By  improved  sanitary  practices,  involving  the  suppression  of  spitting,  the 
segregation  of  dangerous  consumptives,  an  improvement  in  methods 
and  equipment  for  living,  including  adequate  housing  to  prevent  in- 
evitable infection  through  congestion. 

FIND  MORE  EARL  Y  TUBERCULOSIS 

If  tuberculosis  is  to  be  combated  successfully,  cases  must  be  found  early. 
In  Cleveland,  as  elsewhere,  the  next  step  in  tuberculosis  is  the  first  step; 
namely,  find  the  undiscovered,  early  cases. 

1.  By  educational  methods,  and  where  violation  is  persistent,  by  legal  meas- 
ures, stimulate  compliance  with  city  ordinance  requiring  the  reporting  of 
tuberculosis  as  soon  as  diagnosis  is  established. 


Tuberculosis  335 


2.  By  the  establishment  of  an  expert  medical  advisory,  consultation  service, 
on  diagnosis  and  treatment,  to  operate  through  the  Health  Centers,  under 
the  auspices  of  the  Division  of  Health,  or  the  Anti-Tuberculosis  League. 

3.  By  providing  post-graduate  medical  training,  through  the  Medical  School, 
or  otherwise,  for  the  training  of  clinic  physicians  and  general  practitioners 
in  the  detection  of  the  incipient  signs  and  symptoms  of  tuberculosis. 

4.  By  providing  a  more  adequate  number  of  nurses  to  find  suspicious  cases 
and  persuade  them  to  come  to  doctors  for  diagnosis,  twice  as  many  nurses 
being  needed  for  the  staff  of  the  Division  of  Health. 

MORE  ADEQUATE  TREATMENT 

1.  By  the  provision  of  500  additional  beds  for  institutional  cases,  for  ad- 
vanced and  early  types,  for  adults  and  children,  at  the  City  Hospital  and 
at  Warrensville. 

2.  By  improved  methods  of  sanatorium  and  hospital  treatment,  encouraging 
the  patients  to  persist  in  the  treatment  until  arrested  or  cured,  and  follow- 
ing them  up  to  insure  proper  social  and  economic  adjustments  to  work 
and  to  life. 

3.  By  providing  more  adequate  home  nursing  care  for  tuberculosis  patients. 
MORE  COMPLETE  ORGANIZATION 

1 .  A  full-time  chief  in  the  Bureau  of  Tuberculosis,  to  aid  and  cooperate  with 
other  agencies  in  the  further  development  of  the  Health  Centers,  the 
institutional  program,  the  post-graduate  training,  the  consultation  serv- 
ice, the  educational  activities,  etc. 

2.  The  adequate  financing  and  staffing  of  the  Anti-Tuberculosis  League  for 
educational  and  possibly  medical  consulting  work,  involving  an  estimated 
annual  budget  of  from  twenty  to  thirty-five  thousand  dollars,  depending 
upon  the  services  undertaken. 

3.  An  educational  program  in  the  schools  and  factories  of  Cleveland  with 
especial  emphasis  upon  the  principles  of  nutrition  and  the  value  of  annual 
periodic  medical  examination  in  preventing  tuberculosis. 


336  Hospital  and  Health  Survey 


II. 
Objects  and  Methods 

THE  carrying  out  of  this  special  study  in  Cleveland  has  been  a  most 
agreeable  task  for  numerous  reasons.  In  the  tuberculosis  field,  Cleveland 
has  been,  in  many  respects,  a  pioneer  community.   Having  accomplished 
much  in  the  past,  it  was  legitimate  for  the  community  now  to  ask:    "What 
is  the  next  step  in  tuberculosis  work  in  Cleveland?" 

In  the  past,  Cleveland,  through  its  health  and  tuberculosis  agencies,  has 
admirably  accepted  the  challenge  to  make  Cleveland  the  national  leader  in 
tuberculosis  work.  Its  past  experience,  coupled  with  a  willingness  to  face 
its  current  and  future  problems  with  patience  and  courage,  gives  promise  of 
exceptional  accomplishments  in  the  future. 

In  discussing  the  prospects  of  future  developments  in  the  Cleveland 
tuberculosis  program  with  the  health  and  civic  leaders  in  the  community, 
one  is  impressed  favorably  with  the  attitude  quite  generally  maintained 
toward  pressing  local  problems.  The  leaders  seem  to  recognize  current 
limitations  in  health  and  tuberculosis  work.  There  is  manifested  an  excellent 
spirit  of  cooperation  and  good  will  between  local  agencies.  The  heads  of 
local  movements  are  forward-looking  and  sympathetic  to  fresh  suggestions. 

The  primary  objects  of  the  tuberculosis  survey  in  Cleveland  were  as 
follows : 

1.  An  analysis  of  "past  history"  as  to  tuberculosis,  a  study  of  its  past  inci- 
dence as  to  mortality  and  morbidity,  an  analysis  of  previous  experience 
as  to  methods  of  control,  etc. 

2.  A  study  of  the  present  problem,  its  magnitude  and  relative  significance 
as  a  disease  factor  in  the  life  of  the  municipality. 

3.  An  analysis  of  existing  measures  and  equipment  for  meeting  the  problem. 

4.  A  determination  of  the  chief  immediate  needs  and  outstanding  inadequacies 
in  the  present  machinery  for  tuberculosis  control. 

5.  An  approximation  of  the  more  obvious  and  urgent  recommendations  grow- 
ing out  of  such  an  appraisal. 

The  chief  methods  which  have  been  employed  in  studying  the  tubercu- 
losis situation  in  Cleveland  were  the  following: 

1 .  A  statistical  analysis  of  past  and  current  morbidity  and  mortality  experi- 
ence, carried  out  essentially  through  the  generous  cooperation  and  assist- 
ance of  the  City  Division  of  Health. 

2.  A  study  of  Cleveland  literature  bearing  on  tuberculosis  and  allied  sub- 
jects, such  as  housing,  hospital  and  medical  service,  legislation,  etc. 

3.  Visits  to  tuberculosis  agencies  and  institutions,  including  hospitals,  sana- 
toria, open-air  schools,  health  centers,  etc. 


Tuberculosis  337 

4.  A  special  field  study  into  the  particular  problem  of  milk  consumption,  with 
the  cooperation  of  the  Division  of  Health,  the  Associated  Charities,  and 
the  Visiting  Nurse  Association. 

5.  A  study  of  the  results  of  other  phases  of  the  Hospital  and  Health  Survey, 
such  as  the  investigations  of  nursing,  hospital  and  dispensary  work,  in- 
dustrial hygiene,  etc. 

6.  A  study  of  the  maps  and  reports  developed  in  connection  with  other 
Cleveland  surveys,  both  past  and  present,  including  recreation  studies, 
housing  studies,  etc. 

7.  Conferences  with: 

(a)  Investigators   associated   with   the   writer   on   the   Hospital   and 
Health  Survey  staff. 

(b)  Local  leaders  in  health,  tuberculosis,  medical,  social,  educational, 
nursing  and  charitable  activities. 

8.  The  preparation  of  the  report,  with  its  presentation  to  special  conferences, 
public  meetings,  etc. 


338  Hospital  and  Health  Survey 


III. 
Trie  Statistical  Record  of  Tuberculosis  in  Cleveland 

AN  historical  and  statistical  analysis  is  a  prerequisite  in  the  study  of  pre- 
vention and  control  of  any  disease.  It  is  in  the  Dast  records  of  the  disease 
insofar  as  they  are  at  all  reliable  and  comparable  with  established  stand- 
ards, that  one  gathers  an  indication  of  the  relative  importance  of  the  problem 
under  consideration.  In  the  following  report  an  effort  has  been  made  to 
present  the'  essential  facts  of  past  tuberculosis  history.  Every  effort  has 
been  made  in  the  development  of  the  tuberculosis  survey  to  adhere  to  those 
aspects  of  the  problem  which  bear  on  practical  considerations  and  which 
lead  to  tangible  constructive  suggestions. 

Much  of  the  detailed  statistical  material  presented  in  the  original  manu- 
script report  has  been  eliminated  from  the  data  prepared  for  publication. 
For  much  assistance  and  many  valuable  suggestions  the  writer  is  indebted 
to  Dr.  G.  W.  Moorehouse,  the  Chief  of  the  Division  of  Communicable  Dis- 
ease of  the  Cleveland  Division  of  Health. 

POPULATION  AND  GENERAL  MORTALITY 

General  Death  Rates. 

The  general  death  rates  for  Cleveland  are  given,  as  furnished  by  the  Division  of 
Health.     (Rates  corrected  according  to  population  estimates  based  on  1920  census  returns.) 

Cleveland  Death  Rates  per  Thousand  Living 


Year 

Population  as  of  July  1st 

Rate 

1910 

564,066 

14.3 

1911 

587,936 

13.5 

1912 

611,806 

13.4 

1913 

635,676 

13.9 

1914 

659,546 

12.5 

1915 

683,416 

12.9 

1916 

707,286 

14.1 

1917 

731,156 

14.8 

1918 

755,026 

17.3 

1919 

778,896 

12.7 

Since  the  preparation  of  this  material  the  official  report  of  the  population  of  Cleveland 
has  been  published  by  the  Bureau  of  Census,  as  of  January,  1920.  This  credits  Cleveland 
with  a  population  of  796,836  individuals.  It  will  be  necessary  for  those  who  contemplate 
accurate  statistical  study  of  the  incidence  and  death  rates  from  tuberculosis  in  Cleveland 
and  other  American  cities  to  base  their  estimates  upon  the  arithmetical  increase  indicated 
by  the  difference  between  the  1910  and  1920  census  reports. 


Tuberculosis  339 

Leading  Causes  of  Death. 

In  endeavoring  to  secure  figures  for  the  leading  causes  of  death  in  Cleveland,  the 
last  available  year  (1918)  was  ignored,  because  of  the  extreme  conditions  resulting  from  the 
influenza  epidemic.     The  figures  given  are,  therefore,  for  1917. 

It  may  be  interesting  to  contrast  Cleveland  conditions  with  conditions  prevailing 
in  the  State  of  Ohio.  The  leading  causes  of  death  for  1917  in  the  State  of  Ohio,  as  pre- 
pared by  the  State  Department  of  Health,  in  contrast  to  Cleveland,  are  indicated  below. 

It  will  be  observed  that  while  tuberculosis  occupies  third  place  in  the  State  figures, 
it  rises  to  second  place  in  the  city. 

Leading  Causes  of  Death — State  of  Ohio  and  Cleveland — 1917. 

Rate  per  100,000 

Cause                                                                                   State  of  Ohio  Cleveland 

1.  Organic  diseases  of  heart _ 166.08  96.1 

2.  Pneumonia  (all  forms) 148.46  196. 

3.  Tuberculosis  (all  forms) 142.99  174. 

4.  Cancer  and  other  malignant  tumors 91.71  82.5 

5.  Bright's  Disease 87.93  70.1 

6.  Diarrhea  and  enteritis  (under  2  years) 57.87  119. 

TUBERCULOSIS  MORTALITY 

Past  History 

The  past  history  of  tuberculosis  in  Cleveland  presents  a  picture  similar  to  that  of  other 
sections  of  the  United  States.  That  there  has  been  a  general  decline  in  the  tuberculosis 
death  rate  and  in  the  percentage  mortality  for  tuberculosis  is  seen  in  the  following  figures 
taken  from  a  study  by  Dr.  G.  E.  Harmon,  as  published  in  the  Cleveland  Medical  Jour- 
nal for  May,  1915. 

Tuberculosis  Death  Rates  for  Cleveland  from  1865  to  1914 

Death  Rate  per  100,000  for  All  Per  Cent  Pulmonary  Tuberculosis 

Deaths  of  Total  Deaths 
11.7 
9.1 
8.6 
7.4 
9.0 
7.6 
9.5 
8.2 
8.4 
8.4 


Period 

Forms  of  Tuberculosis 

1865-1869 

225 

1870-1874 

178 

1875-1879 

203 

1880-1884 

178 

1885-1889 

164 

1890-1894 

144 

1895-1899 

134 

1900-1904 

128 

1905-1909 

129 

1910-1914 

136 

340  Hospital  and  Health  Survey 

It  is  questionable,  owing  to  inaccuracies  in  reporting,  variation  in  certification,  etc., 
whether  the  figures  previous  to  1880  are  of  any  real  significance.  It  will  be  noted,  however, 
that  while  there  has  been  a  general  decline  in  tuberculosis  mortality  in  the  last  few  decades, 
the  more  recent  tendency  since  1900  has  been  upward.  This  tendency  will  be  borne  out 
by  figures  to  be  presented  subsequently  with  reference  to  the  years  since  1914.  Appar- 
ently the  efforts  for  tuberculosis  control  in  the  past  have  assisted  the  natural  tendency 
toward  the  reduction  in  mortality.  On  the  other  hand,  if  this  tendency  is  to  be  re-attained, 
fresh  efforts,  and  perhaps  new  measures,  will  have  to  be  found  for  the  future.  (See  also 
chart  on  page  341.) 

Comparisons  with  Other  Cities. 

For  the  period  1913  to  1917,  inclusive,  the  relationship  which  Cleveland  has  borne 
to  two  cities  comparable  in  size  and  in  industrial  make-up  in  the  Great  Lakes  region  is 
here  shown. 

Death  Rates  from  Tuberculosis,  All  Forms 

City  1913  1914  1915  1916  1917  Average 

Buffalo 156.0  165.8  157.0  162.2  169.2  162.0 

Detroit. 116.0  121.8  135.6  163.9  159.9  139.4 

Cleveland... 131.7  136.3  132.6  152.7  174.0  145.4 

It  will  be  noted  that  in  these  cities  there  is  a  slight  tendency  for  the  rate  to  increase 
during  this  period  of  years.  The  average  for  Cleveland,  however,  compares  favorably 
with  that  of  the  other  two  cities,  particularly  with  Buffalo.  The  death  rate  for  Cleve- 
land for  1917,  according  to  the  Cleveland  Division  of  Health,  is  175  per  100,000,  in- 
stead of  174.  The  figures  in  this  table  are  taken  from  the  Federal  mortality  statistics 
report. 

The  percentage  of  total  tuberculosis  deaths  which  are  attributed  to  pul- 
monary tuberculosis  in  1918,  in  ten  of  the  leading  cities  of  the  United  States, 
according  to  the  local  registrars,  shows  Cleveland's  position  in  the  series. 

Per  Cent  of  Total  Tuberculosis  Deaths 

in  1918  Attributed  to  Pulmonary 

Tuberculosis 

Cincinnati..... 94 

Philadelphia....... 90.2 

Newark,  N.  J 90.1 

St.  Louis.- 89.7 

Buffalo. 87.3 

New  York._ _ 86.9 

Boston 86.7 

Cleveland. 85.7 

Detroit 84.7 

Pittsburgh __ 82 

The  Cleveland  death  rate  from  tuberculosis  (all  forms)  for  1918  showed 
a  decided  drop,  being  recorded  as  147  per  100,000.  This,  however,  is  largely 
the  reflection  of  the  unusual  estimated  increase  in  population  hitherto  referred 
to,  and  the  result  of  influenza  which  masked  many  deaths  in  tuberculous 
individuals,  not  recorded  as  tuberculosis. 


Tuberculosis 


341 


CLEVELAND  DEATH  RATES  FROM  PULMONARY  DISEASE— 1850  TO  1919 

(Chart  prepared  by   Dr    G.    W.   Moorehouse) 

PULMONARY   TUBERCULOSIS   AND   NON-TUBERCULOUS   PULMONARY 
DISEASES,   CLEVELAND,  OHIO— 1850  TO   1919 

Mortalities  per  10,000,  average  of  five-year  periods. 

Pulmonary  tuberculosis:  Solid  line, 

Non-tuberculous  pulmonary  diseases:  Lower  broken  line,  -.-, — — _ _ 
Pulmonary  diseases,  tuberculous  and  non-tuberculous:  Upper  broken  line, .- . 

1852      1857       1862        1867       1872       1877       1882       1887       1892       1897       1902       1907       1912       1917 


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1873 — First  Board  of  Health  of  Cleveland. 

1882 — Koch's  discovery  of  the  tubercle  bacillus. 

1901 — City  Bacteriological  Laboratory  opened.  Disinfection  after  death  from  tuber- 
culosis begun. 

1904 — Tuberculosis  dispensary  opened  by  the  Anti-Tuberculosis  League. 

1905— International  Classification  of  Causes  of  Death  first  used  in  Cleveland.  Smallpox 
Hospital  on  City  Hospital  grounds  renovated  and  opened  as  a  sanatorium  for 
tuberculosis. 

1906 — Tuberculosis  dispensary  started  in  City  Hall.  Open  evenings.  Discontinued  after 
a  few  months.    Tuberculosis  made  reportable. 

1907 — Tent  colony  opened  by  the  Anti-Tuberculosis  League.  In  1915  this  was  moved  to 
Warrensville  and  the  expense  of  maintenance  borne  by  the  City. 

1910 — City  took  over  tuberculosis  dispensary  which  had  been  maintained  by  the  Anti- 
Tuberculosis  League  and  opened  two  other  tuberculosis  dispensaries. 

1911,  13,  14,  15 — Additional  dispensaries  were  opened. 

1913 — New  sanatorium  at  Warrensville  opened. 

1914 — Day  camp  in  operation  during  the  summer.  Operated  one  or  two  years  and  then 
discontinued. 

1915 — Compulsory  pasteurization  of  all  (except  Grade  A)  milk  used  in  the  city. 


342  Hospital  and  Health  Survey 


Tuberculosis  Deaths  by  Age. 

The  distribution  of  tuberculosis  deaths  by  certain  age  groups  for  the  period  1913  to 
1918,  inclusive,  is  presented  in  Table  I.  (Appendix). 

As  usual,  it  is  seen  that  the  non-pulmonary  deaths  are  high  under  five  years  of  age. 
The  total  deaths  under  five  constitute  7.3  per  cent  of  all  the  tuberculosis  deaths  for  the 
period.  It  will  also  be  noted  that  the  deaths  for  the  age  periods  20-39  total  just  50  per 
cent  of  all  the  deaths  from  tuberculosis.  This  reflects  the  high  mortality  in  the  industrial 
age  period,  and  also  reflects  the  large  male  industrial  population. 

From  this  table  it  may  also  be  seen  that  the  non-pulmonary  deaths  constitute  13.6 
per  cent  of  the  total  deaths. 

The  tuberculosis  death  rates  by  estimated  population  for  age  groups  are  shown  in 
Table  II.  (Appendix). 

Tuberculosis  Deaths  by  Sex. 

The  distribution  of  tuberculosis  deaths  by  sex  is  indicated  in  Table  III.  (Appendix). 

From  this  table  it  will  be  seen  that  the  deaths  among  males  constitute  64  per  cent 
of  the  total.  This  high  male  tuberculosis  mortality  is  to  be  considered  in  connection  with 
the  high  percentage  mortality  for  the  industrial  age  groups  (50  per  cent)  as  pointed  out 
in  the  discussion  of  Table  I. 

Occupation. 

Through  the  cooperation  of  the  Division  of  Health  the  distribution  of  tuberculosis 
deaths  by  occupations  was  obtained  for  the  period  1914  to  1918.  It  is  perhaps  not  worth 
while  to  present  all  of  these  figures,  but  in  Table  IV.  there  is  given  the  total  number  of 
deaths  by  occupation  for  these  five  years,  according  to  the  18  leading  occupations  of  those 
dying  of  tuberculosis. 

The  prominence  of  "housework"  is  a  typical  finding  and  seems  to  indicate  not  so  much 
the  hazardous  nature  of  housework  as  the  fact  that  the  majority  of  tuberculosis  patients 
among  women  are  not  found  in  industry,  but,  by  the  time  they  become  active,  do  gravi- 
tate to  the  home,  and  are  consequently  recorded  as  being  "at  home"  or  "housewives,"  or 
as  doing  housework. 

Important  evidence  has  been  recently  collected  and  published  by  Dr.  George  M. 
Kober  in  United  States  Public  Health  Reports  (March  26,  1920,  Vol.  35,  No.  13),  showing 
increasing  damage  properly  attributable  to  occupations  as  a  contributing  factor  in  pul- 
monary tuberculosis,  as  well  as  the  substantial  results  which  have  been  obtained  in  reducing 
tuberculosis  where  dusts  and  other  air  pollutions  have  been  controlled  or  reduced  in  a 
variety  of  trades.  Such  studies  as  are  here  reported  by  Dr.  Kober  must  be  undertaken 
in  Cleveland  if  the  true  nature  and  extent  of  industrial  hazards,  as  accessory  causes  of 
tuberculous  diseases  among  the  operatives  in  metal  and  textile  trades  and  in  mercantile 
establishments,  are  to  be  appreciated  and  removed.  The  relationship  of  the  pollution  of 
the  air  of  the  city  by  coal  dust,  ash  and  trade  wastes,  permitted  to  escape  from  chimneys 
without  any  pretense  at  effective  restriction,  is  well  worth  studying,  district  by  district. 

Form. 

The  percentage  of  non-pulmonary  deaths  (Table  V.,  Appendix)  is  a  fairly  satisfactory 
showing,  though  with  a  concentration  upon  the  detection  of  early  disease  and  upon  the 


Tuberculosis  -  343 

stimulation  of  tuberculosis  reporting,  and  upon  the  encouragement  of  greater  reliability 
in  death  certification,  it  is  probable  that  this  percentage  would  be  increased. 

Residence. 

As  previously  stated,  the  figures  for  tuberculosis  deaths  and  mortality  rates  for  Cleve- 
land do  not  include  deaths  among  Cleveland  residents  at  Warrensville  Tuberculosis  Sana- 
torium. On  the  other  hand,  they  do  include  deaths  among  non-residents  in  Cleveland. 
It  would,  of  course,  be  more  logical  to  exclude  non-residents  and  to  include  Warrensville 
deaths,  but  the  practice  has  not  been  carried  out  in  the  past. 

As  a  matter  of  fact,  however,  an  analysis  of  the  reports  of  deaths  in  1918  and  1919 
indicates  that  these  two  factors  approximately  balance. 

For  1918  the  non-residents  dying  in  Cleveland  (residence  less  than  one  year)  were  42. 
For  1919  this  number  was  38.  On  the  other  hand,  for  1918  it  was  estimated  by  the  Divi- 
sion of  Health  that  the  residents  dying  out  of  town  number  46.  The  actual  difference 
would  make  only  a  slight  modification  in  the  tuberculosis  rate. 

TUBERCULOSIS  MORBIDITY 
Reporting. 

During  the  study  in  Cleveland,  physicians  and  others  frequently  expressed  the  opinion 
that  the  reporting  of  tuberculosis,  as  well  as  of  births,  was  incomplete.  This  is,  of  course, 
more  or  less  reflected  in  the  ratio  of  reported  cases  to  deaths,  which  will  be  touched  upon 
shortly. 

As  will  be  described  in  more  detail  later,  the  ratio  of  active  cases  to  annual  deaths  in 
Cleveland  is  running  about  4.7  to  one.  In  Framingham,  Mass.,  this  ratio  for  active  cases 
during  the  most  intensive  year  (November,  1917,  to  November,  1918)  of  the  work,  was  in- 
creased to  approximately  nine  to  one — 115  cases  to  13  deaths.  It  is  stated  by  the  Division 
of  Health  that  20  to  30  per  cent  of  the  tuberculosis  deaths  are  not  reported  as  cases  before 
death. 


1918 

1919 

1920 
(4  mos.) 

1020 

841 

260 

285 

190 

61 

27.9% 

22.5% 

23.5% 

Deaths  from  pulmonary  tuberculosis  

Not  reported  as  pulmonary  tuberculosis  before  death 
Per  cent  of  unreported  cases  

In  Framingham,  Mass.,  this  percentage  runs  about  6. 

On  the  other  hand,  this  is  comparing  the  Cleveland  conditions  with  experimental 
and  more  or  less  ideal  conditions.  The  ratio  of  4.7  to  1  for  cases  and  deaths  is  a  better 
ratio  than  will  be  found  in  many,  if  not  most,  other  American  cities. 

Case  Classification. 

While  the  method  of  case  classification  at  the  health  centers  and  at  the  Division  of 
Health  has  been  worked  out  on  a  good  practical  routine  basis,  it  is,  as  would  be  the  case 
in  most  communities,  not  wholly  satisfactory.  A  modified  method  of  case  bookkeeping, 
based  on  a  somewhat  altered  system  of  case  classification,  has  been  suggested  in  some 
detail  to  the  department  officials.     Such  a  system  as  has  been  proposed,  if  carried  out  in 


344  .  Hospital  and  Health  Survey 

each  health  district,  supplemented  by  monthly  summaries  to  the  central  office,  would  have 
a  great  many  advantages.  It  would  help  to  visualize  the  situation  as  it  runs  in  the  health 
districts  from  month  to  month.  It  would  facilitate  a  summarization  of  cases  according 
to  classification  groups  at  any  time.  It  would  encourage  the  more  persistent  follow-up 
of  arrested  cases  and  suspicious  cases. 

Health  Center  Attendance. 

The  details  as  to  actual  attendance  at  the  health  centers  for  a  period  of  years  are 
indicated  in  Table  VI.  (Appendix). 

The  totals  for  these  years  indicate  a  decided  falling  off  in  attendance,  the  total  drop- 
ping from  14,753  in  1915  to  10,765  in  1918.  This  has  been  a  common  experience  else- 
where. 

New  Cases  at  the  Health  Centers. 

The  total  number  of  new  cases  at  the  health  centers  is  indicated  in  Table  VII.  (Ap- 
pendix). 

Here  again  will  be  found  a  falling  off  in  new  cases,  the  total  for  1915  being  3,416,  and 
that  for  1918  being  2,482.  This  falling  off  of  new  cases  in  dispensaries  and  health  centers 
is  not  unique  in  Cleveland,  but  is  characteristic  of  other  cities.  In  New  York,  for  in- 
stance, there  were  4,010  fewer  cases  on  the  records  in  1918  than  in  1917.  This  has  been 
ascribed  to  a  number  of  reasons,  including  the  following: 

1 .  The  fact  that  during  part  of  the  period  a  very  large  percentage  of  the  male 
population  in  the  most  susceptible  age  group  had  been  drafted  into  the 
army. 

2.  The  hold  which  the  war  industries  have  had  upon  the  working  population, 
and  the  unwillingness  on  the  part  of  anyone  to  forego  the  high  wages 
unless  absolutely  compelled  to  do  so  by  prostrating  illness. 

3.  The  falling  off  of  immigration. 

4.  The  general  let-down  in  anti-tuberculosis  educational  work. 

5.  The  fact  that  the  influenza  epidemic  may  have  killed  off  a  large  percentage 
of  the  individuals  who  might  subsequently  have  been  reported  as  tubercu- 
lous cases. 

Active  Cases. 

The  grand  total  of  cases  for  all  of  the  health  districts  was  5,565,  while  the  actual 
active  cases  on  record  at  each  of  the  health  districts  were  as  follows : 


District 

No. 

of  Cases 

1 

697 

2  and  8 

1157 

3 

464 

4 

430 

5 

1092 

6 

859 

7 

886 

Tuberculosis  345 


Ratio  of  Active  Cases  to  Deaths. 

The  ratio  of  active  cases  to  deaths  for  all  the  districts  combined  is  4.7  to  1.  The 
total  number  of  deaths  for  1918  is  1,190.  This  includes  1,073  cases  distributed  by  health 
districts,  and  117  deaths  of  residents  out  of  town,  or  of  non-residents  in  town. 

New  Tuberculosis  Cases  Reported  in  1919. 

The  total  number  of  pulmonary  tuberculosis  cases  reported  in  1919  was  1,442.  For 
the  entire  city  the  ratio  of  newly  reported  cases  to  deaths  is  1.2  to  1. 

The  Stage  of  the  Disease  as  Reported. 

The  stage  of  the  disease  as  reported  is  not  only  a  measure  of  the  accuracy  of  reporting, 
but  also  indicates  the  relative  efficiency  of  the  medical  profession  in  the  early  detection  of 
the  disease. 

Through  the  help  of  the  Division  of  Health  it  was  possible  to  make  two  separate 
tests  in  reference  to  the  stage  of  reporting.  Five  hundred  cases  were  classified  according 
to  stage  as  reported  at  health  centers  2  and  5.  Here  it  was  found  that  of  the  total  number 
of  cases  reported  43.6  per  cent  were  classified  as  early  cases. 

Again,  at  the  Division  of  Health  a  group  of  500  were  classified  according  to  the  stage 
in  which  they  were  reported  by  the  physicians.  These  were  cases  which  came  in  indepen- 
dent of  the  health  centers.  In  this  group  51  per  cent  were  reported  in  the  first  stage.  In 
contrast  to  these  two  percentages  for  the  health  centers  and  for  the  Division  of  Health 
of  43.6  and  51,  respectively,  it  may  be  stated  that  in  Framingham,  Massachusetts,  where 
a  special  effort  has  been  made  to  encourage  reporting,  the  percentage  for  the  last  three 
years  has  averaged  74. 

It  is  evident  that  something  could  be  done  in  Cleveland  to  improve  upon  this  factor. 
The  discovery  of  the  disease  in  its  early  stages,  in  order  that  treatment  may  be  applied 
when  most  effective,  is  of  vital  importance  in  the  control  of  the  disease. 


346  Hospital  and  Health  Survey 

IV. 

General  Provisions  for  Attack  and    Defense  Against 

Tuberculosis 

THE  machinery  which  a  community  constructs  for  its  defense  against 
disease  is  of  two  main  types :  first,  certain  general  measures,  such  as  educa- 
tion, legislation,  general  sanitation,  nutrition,  etc.;  and,  second,  certain 
specific  devices,  such  as  institutions  or  clinics  for  the  special  care  of  the 
particular  disease  under  consideration.  The  present  chapter  will  be  devoted 
to  a  brief  review  of  the  Cleveland  equipment  for  meeting  the  tuberculosis 
problem,  from  the  more  general  point  of  view. 

EDUCATION 

There  cannot  be  said  at  present  to  be  any  organized  attempt  in  schools  or  for  the 
public  to  carry  on  systematic  education  in  the  nature,  cause  and  prevention  of  tuberculosis. 

LEGISLATION 

For  the  Direct  Control  of  Tuberculosis. 

Cleveland  is  well  equipped  with  measures  for  tuberculosis  control.  The  more  im- 
portant legislation  may  be  summarized  as  follows: 

1.  Provision  for  the  disinfection  of  premises  (1901). 

2.  The  prohibition  of  spitting  (1905). 

3.  Tuberculosis  a  reportable  disease  (1907). 

4.  Provision  made  for  compulsory  removal  and  detention  of  dangerous 
tuberculosis  cases — practical  segregation  (1910). 

5.  Prohibition  of  the  employment  of  any  person  suffering  from  tuberculosis 
in  a  school  (1914),  and  the  prohibition  of  the  employment  of  any  tubercu- 
lous individual  in  a  food  handling  establishment  (1914). 

6.  Legislation  against  common  drinking  cups  (1919). 

With  Reference  to  Milk. 

City  ordinance,  No.  34648-A  makes  adequate  provision  for  the  control  of  the  milk 
supply  of  the  city  of  Cleveland.  This  ordinance  includes  measures  prohibiting  the  sale 
of  dipped  milk;  requiring  that  all  certified  milk  be  obtained  from  tuberculin  tested  and 
negatively  reacting  cattle,  from  regularly  inspected  plants,  handled  by  medically  inspected 
employes;  that  all  milk  be  sold  according  to  specified  grades;  that  all  uncertified  milk 
be  pasteurized;  that  all  pasteurization  be  according  to  the  holding  process  for  definite 
temperatures,  etc. 

Housing. 

In  Cleveland,  houses  while  under  construction  are  under  the  supervision  of  the  Divi- 
sion of  Buildings  of  the  Department  of  Public  Service.  When  occupied,  so  far  as  general 
control  is  concerned,  they  are  under  the  Bureau  of  Sanitation  of  the  Division  of  Health. 


Tuberculosis  347 


Legislation  has  been  provided,  along  the  lines  of  the  regulation  housing  code,  known 
as  ordinance  No.  32186-A,  which  apparently  makes  adequate  provision  for  hygienic  equip- 
ment and  control.  Certain  sections  of  this  code  cover  specific  matters  of  direct  importance 
to  personal  hygiene  and  home  living  methods,  including  water  supply,  water  closets, 
general  cleanliness,  etc.  It  was  not  possible  to  make  an  exhaustive  comparative  analysis 
of  housing  legislation  in  Cleveland,  but  a  cursory  study  of  the  provisions  would  seem  to 
indicate  that  the  legislation  is  reasonably  adequate."  The  question  as  to  its  actual  enforce- 
ment will  be  discussed  later. 

GENERAL  SANITATION 

It  has  been  pointed  out  that  the  community  is  well  equipped  as  regards  sanitary 
legislation.  How  adequately  is  that  legislation  enforced?  This  question  cannot  be 
answered  from  the  point  of  view  of  minute  details  of  general  sanitary  provisions.  It  has 
been  considered  only  in  its  more  important  aspects. 

The  Milk  Problem. 

Through  the  cooperation  of  the  Division  of  Health  and  the  Cleveland  Consumers' 
League,  fairly  definite  answers  were  secured  to  specific  questions  with  reference  to  the 
milk^situation  in  Cleveland. 

The  Consumers'  League  investigators  reported: 

l.jThat  the  estimated  total  milk  consumption  in  Cleveland  was  60,000  gal- 
lons per  day.     (80,000  including  milk  used  for  ice  cream.) 

2.  That  one  concern,  the  Telling-Belle- Vernon  Company,  handles  about 
40  per  cent  of  this  entire  supply. 

3.  That  practically  all  of  the  milk,  except  the  certified,  is  pasteurized,  the 
amount  pasteurized  approximating  98  per  cent  of  the  total  supply. 

4.  That  about  300  gallons  per  day  is  certified,  or  approximately  .37  per  cent 
of  the  total. 

The  bacterial  content  of  this  certified  milk  is  kept  below  10,000. 

5.  This  would  leave  about  2  per  cent  of  the  supply  in  the  unpasteurized 
class.  The  bacterial  content  of  this  milk  is  limited  by  legislation  at  50,000, 
but  was  said  to  be  running  at  15,000  in  the  winter  months.  All  of  this 
raw  milk  comes  from  tuberculin  tested  cattle,  the  tests  being  made  once 
a  year. 

6.  Pasteurization  is  by  the  holding  process,  at  145°  F.  for  30  minutes. 

7.  At  the  present  time  about  10  per  cent  of  the  total  milk  supply  is  said  to 
be  sold  at  retail  as  dipped  milk. 

From  control  observations  made  by  bacterial  counts  of  milk  samples  taken  in  the 
open  market,  as  delivered  to  the  consumer  in  March  and  June,  it  is  apparent  that  although 
the  inspection  service  appears  to  be  thorough  and  conscientious,  not  more  than  half  the 
milk  sold  complies  with  the  legal  sanitary  standards  of  bactei  ial  purity. 


348  Hospital  and  Health  Survey 

Milk  Consumption — Its  Dietary  and  Nutritional  Aspects. 

Tuberculosis  usually  results  from  the  inter-play  of  a  number  of  factors.  These  may 
be  environmental,  such  as  bad  housing,  unsanitary  surroundings,  low  wages,  etc.;  indi- 
vidual or  race  habit,  such  as  the  prevalence  or  absence  of  maternal  nursing,  adequate  or 
inadequate  food  habits,  etc.;  and  finally,  race  stock. 

There  is  no  doubt  that  nutrition,"  related  as  it  is  to  race  habits,  economic  status  and 
general  education  is  of  basic  importance  in  the  incidence  of  disease  and  perhaps  particu- 
larly of  tuberculosis.  Just  how  important  nutrition  is  in  tuberculosis  we  do  not  yet  know. 
Possibly  certain  studies  now  being  planned  will  throw  light  on  this  problem. 

So  far  as  the  Cleveland  situation  is  concerned,  it  has  seemed  worth  while  to  make  a 
modest,  though  intensive,  effort  to  study  some  factors  of  the  most  important  single  food 
consumption  problem;  namely,  the  question  of  milk.  This  problem  is  of  importance  not 
only  to  children,  but  to  adults  as  well. 

A  somewhat  similar  study  carried  out  recently  in  Framingham,  Mass.,  indicated  that 
69  representative  families,  with  173  adults  and  261  children,  were  taking  92  quarts  of 
milk  a  day.  Now  if  each  child  under  2  requires  a  quart  of  milk,  and  if  each  family  should 
use  in  addition  at  least  a  pint  per  capita  for  the  fundamental  cooking  necessities  for  proper 
diet  for  adults,  it  is  evident  that  this  group  should  have  been  consuming  between  two 
and  three  times  as  much  milk  per  day  as  they  did. 

In  Cleveland,  with  the  help  of  the  Division  of  Health  Nursing  Bureau,  the  Visiting 
Nurse  Association  and  the  Associated  Charities,  an  effort  has  been  made  to  make  a  some- 
what similar  analysis  of  the  situation  in  a  thousand  families. 

The  results  from  this  study  may  be  presented  in  the  following  way: 
/.   Agencies  for  Families  Covered. 

Division  of  Health 536  families 

Associated  Charities 310        " 

Visiting  Nurse  Association 154        " 


1000  families 

Distribution  of  Families  by  Health  Districts. 

District  1 15.6  per  cent 

District  2 6.9  "       " 

District  3. '. 18.9  "       " 

District  4. 10.9  " 

District  5 12.  " 

District  6 21. 

District  7... 9.3  " 

District  8 2.2  " 

Outside  or  not  stated 3.2  "       " 

100      per  cent 


Tuberculosis  349 

It  is  evident  from  this  table  that  these  families  were  fairly  generally  distributed  over 
all  parts  of  Cleveland. 

3.  A  Census  of  the  Group  Covered. 

Of  the  1000  families,  117,  or  11.7  per  cent,  were  taking  lodgers. 

A  distribution  of  the  population  by  age  groups  in  these  families  was  as  follows: 

Adults  (adults  and  relatives  over  14) 2221 

Children  (6  to  14) , .". 1541 

Children  (under  6) 1534 

Lodgers 217 

5513 

From  the  foregoing  it  will  be  observed  that  the  census  of  the  families,  excluding  lodgers, 
totaled  5296.     The  total  number  of  children  under  14  was  3075. 

The  number  of  children  per  family  was  3.1.  The  number  of  individuals  per  family 
(without  lodgers)  was  5.3.  The  number  of  individuals  per  household  (including  lodgers) 
was  5.5. 

4.  Relief  and  Non-Relief  Families. 

Families  receiving  relief. 42.7  per  cent 

Families  not  receiving  relief. 57.3     "       " 


100        "       " 

5.  Kinds  of  Relief. 

The  kinds  of  relief  being  received  by  the  42.7  per  cent  of  the  entire  group  of  families 
may  be  stated  as  follows:  money,  9.6  per  cent;  food,  21.2  per  cent;  clothing,  13.6  per 
cent;  medical  care,  24.9  per  cent;  not  stated,  2.6  per  cent.  These  percentages  do  not  of 
course  total  100  in  view  of  the  fact  that  the  percentages  were  calculated  on  the  basis  of 
the  entire  group.     Further,  many  of  the  families  were  receiving  two  or  more  kinds  of  relief. 

6.  Sickness  Prevalence. 

While  it  was  realized  that  the  group  being  covered  was  in  no  sense  typical  of  the 
population  as  a  whole,  it  was  thought  worth  while  to  take,  in  an  informal  way,  a  sickness 
census  of  the  families  reached  by  the  study.  The  illnesses  recorded  were  classified  accord- 
ing to  the  headings  indicated  in  Table  VIII.    (See  Appendix). 

This  is  of  course  an  atypical  group,  and  is  not  to  be  compared  with  other  standard 
sickness  censuses.  It  will  be  remembered  that  the  Metropolitan  sickness  surveys  have 
shown  a  prevalence  of  illness  ranging  from  1.5  to  2.5  per  cent.  These  percentages  apply 
to  incapacitating  illnesses.  The  sickness  census  in  Framingham,  including  minor  illnesses 
as  well  as  major  affections,  showed  a  percentage  sick  of  6.2  per  cent.  This  special  study 
in  Cleveland  of  a  group  being  covered  by  nurses  and  relief  workers,  for  a  number  of  causes, 
including  medical  as  well  as  nursing  needs,  showed  the  percentage  ill,  for  adults  and  chil- 
dren combined,  12.7  per  cent.     For  adults  the  percentage  was  16.16  and  for  children  10.14. 


350  Hospital  and  Health  Survey 


A  special  tabulation  has  also  been  made  of  the  prevalence  in  the  group  not  only  of 
active  tuberculosis,  but  of  suspected  tuberculosis,  and  of  individuals  exposed  to  tubercu- 
losis.    The  results  are  presented  in  Table  IX.  (Appendix). 

From  Table  IX.  it  will  be  observed  that,  for  adults  and  children  combined,  the  num- 
ber being  recorded  as  actively  tuberculous  constitute  2.11  per  cent  of  the  entire  group. 
This  again  reflects  the  fact  that  the  group  is  not  a  typical  group.  A  typical  cross  section 
of  such  a  community  as  Cleveland  if  actually  medically  examined  would  show  the  presence 
of  approximately  one  per  cent  actively  tuberculous,  according  to  Framingham  experience 
and  standards.  It  will  be  observed  that  for  the  group  as  a  whole,  including  adults  and 
children,  3.5  per  cent  were  classified  as  being  either  actively  tuberculous  or  showing  sus- 
picious signs  or  as  having  been  exposed  to  the  disease. 

7 .  The  Number  of  Families  Taking  Milk. 

The  number  of  families  in  the  group  actually  taking  milk  and  the  way  in  which  milk 
was  received  is  shown  in  Table  X.  (Appendix). 

Owing  to  a  duplication  in  this  table  it  is  impossible  of  course  to  have  percentages  or 
numbers  total.  It  will  be  observed,  however,  that  77.9  per  cent  of  the  families  were  re- 
ceiving milk  in  bottles.  The  percentage  of  families  in  which  milk  was  bought  in  whole  or 
in  part  by  bulk  was  3  per  cent.  It  will  be  remembered  that  previously  it  was  stated 
that  approximately  10  per  cent  of  the  milk  in  Cleveland  was  being  sold  as  dipped  milk. 
From  these  two  observations  it  appears  probable  that  some  of  this  dipped  milk  is  not  being 
distributed  through  ordinary  family  channels. 

8.  Home  Refrigeration. 

In  answer  to  the  question  as  to  whether  or  not  the  milk  was  kept  cold,  the  question- 
naires answered  this  inquiry  in  the  affirmative  in  76.5  per  cent  of  the  cases,  in  the  nega- 
tive in  6.5  per  cent,  and  failed  to  answer  in  17  per  cent.  It  will  be  remembered  that  this 
survey  took  place  during  the  winter  season. 

9.  Was  the  Milk  Kept  Covered  at  Home? 

The  families  were  classified  as  follows  under  these  headings:  yes,  80  per  cent;  no,  4.6 
per  cent;   not  stated,  15.4  per  cent. 

It  would  appear  from  these  inquiries  that,  so  far  as  this  season  of  the  year  is  con- 
cerned at  least,  the  home  methods  as  regards  milk  handling  are  above  average  in  Cleve- 
land. 

10.  The  Daily  Amount  of  Milk  Consumed. 

This  of  course  is  a  point  of  vital  importance.  How  much  milk  were  these  families 
consuming,  and  how  does  their  total  milk  consumption  and  average  milk  consumption 
compare  with  the  theoretically  desirable  use  of  milk  for  such  a  group  of  the  Cleveland 
population?  Apparently  the  sanitary  aspects  of  the  milk  situation  are  passable.  How 
about  the  nutritional  and  dietary  sides  of  the  problem? 

The  approximate  amount  of  milk  consumed  as  recorded,  in  the  group,  will  be  shown 
in  Table  XI.  (Appendix).  Milk  purchased  in  canned  form  is  relatively  only  a  small  frac- 
tion of  the  total,  and  has  been  eliminated  from  this  tabulation.  Consequently,  the  sum 
of  the  families  does  not  equal  1000. 


Tuberculosis  351 


From  this  table  it  will  be  observed  that  the  920  families  were  taking  1480  quarts  of 
milk  a  day,  or  1.61  quarts  per  family.  How  does  this  compare  with  the  normal  needs  of 
this  group? 

The  920  families  contained  2852  children.  On  the  basis  of  one  quart  per  child  per  day 
this  would  mean,  for  the  children  alone,  2852  quarts.  If  there  is  added  to  this  one  pint 
for  the  general  family  needs,  or  460  quarts,  the  total  requirements  of  the  group  are  3312 
quarts  daily.  Consequently,  the  families  were  securing  only  44  per  cent  of  the  amount 
of  milk  necessary  or  at  least  desirable  to  meet  their  nutritional  needs. 

To  put  the  matter  in  another  way,  as  there  were  3.1  children  per  family  the  quarts 
per  day  necessary  for  the  average  family  would  be  3.6  quarts.  This  need  is  to  be  contrasted 
with  the  actual  consumption  of  1.61  quarts  per  day. 

//.  Milk  Consumption  by  Relief  and  Non- Relief  Families. 

With  reference  to  milk  consumption  in  bottle  or  bulk  only,  the  amount  purchased  by 
relief  families  is  shown  in  Table  XII.  (Appendix). 

From  this  table  it  will  be  observed  that  each  family  was  securing  1.67  quarts  per  day' 
The  390  relief  families  theoretically  totaled  1209  children  (on  the  basis  of  3.1  children 
per  family),  and  if  to  this  is  added  one-half  quart  for  each  family,  the  total  need  of  the 
relief  families  would  be  represented  by  1404  quarts  daily.  The  amount  of  milk  consumed, 
or  654  quarts,  represents  46  per  cent  of  this  theoretical  need. 

The  situation  as  discovered  in  non-relief  families  is  indicated  in  Table  XIII.  (Ap- 
pendix). 

The  non-relief  families  were  receiving  on  an  average  of  1.58  quarts  per  family,  or  a 
little  less  than  the  relief  families  (1.67).  The  530  non-relief  families  would  total  1643 
children,  and  would  require,  with  a  half  quart  for  additional  family  needs,  a  total  of  1908 
quarts  per  day.  The  actual  amount  consumed,  or  839.25  quarts,  represents  43  per  cent 
of  this  theoretical  need. 

Evidently  the  families  not  receiving  relief  are  receiving  less  milk  than  the  relief  fami" 
lies,  which  probably  reflects  the  effect  of  relief  measures  and  possibly  of  the  educational 
work  being  done  in  the  families  in  contact  with  relief  workers. 

In  justification  of  the  amount  of  time  in  the  investigation  and  the  amount 
of  space  in  the  report,  devoted  to  an  analysis  of  the  consumption  of  milk  in 
Cleveland,  it  is  well  to  recall  the  extent  to  which  milk  is  recognized  as  the 
foundation  of  nutrition,  especially  in  children,  as  is  indicated  in  the  follow- 
ing quotations  from  Public  Health  Reports  (Vol.  35,  No.  17,  April  23,  '20, 
pp.  994-6). 

"Our  present  knowledge  of  nutrition  justifies  more  fully  than  ever  before 
the  statement  that  the  dietary  should  be  built  around  bread  and  milk,  bread 
or  other  grain  products  being  the  foods  which  furnish  the  most  nutriment 
for  their  cost  (whether  in  money  or  in  land  and  labor),  and  milk  being  by  far 
the  most  efficient  nutritional  supplement  to  bread  or  other  grain  products. 
Therefore,  somewhat  more  of  our  grain  crops  than  is  the  case  at  present 
should  come  directly  into  human  consumption  to  augment  the  bread  supply; 
and  of  the  grain  fed  to  cattle  more  should  be  used  for  the  production  of 
milk  and  less  for  the  production  of  meat. 


352  Hospital  and  Health  Survey 

"In  general,  ten  pounds  of  grain  may  be  expected  to  produce  not  over 
one  pound  of  meat  or  about  three  quarts  of  milk.  If  the  three  quarts  of  milk 
cost  the  consumer  more  (because  of  greater  labor  cost  in  production),  they 
are  also  certainly  worth  more  to  him.  In  so  far  as  things  as  different  in  their 
nutritional  properties  as  meat  and  milk  can  be  compared,  it  is  fair  to  say 
that  one  quart  of  milk  is  at  least  as  great  an  asset  in  the  family  dietary  as 
one  pound  of  meat.  The  per  capita  consumption  of  meat  in  the  United  States 
is  so  high  that  it  might  be  reduced  by  onerthird,  or  even  one-half,  with  little 
or  no  nutritional  loss,  while  a  corresponding  increase  in  milk  consumption 
would  certainly  constitute  a  great  improvement  in  the  average  American 
dietary.  We  are  confident  that  a  moderate  shifting  of  emphasis  from  meat 
to  milk  will  help  in  the  normal  evolution  of  American  agriculture  and  im- 
prove the  food  economy  and  public  health  of  the  American  people. 

"Considering  the  whole  length  of  life  of  the  animal,  Prof.  Wood,  the 
leading  English  agricultural  expert,  estimates  that  the  cow  returns  in  milk, 
veal  and  beef  one-twelfth  as  much  food  as  she  has  consumed,  while  the  beef 
steer  returns  only  one  sixty -fourth.  In  other  words,  the  cow  is  five  times 
as  efficient  as  the  beef  steer  as  a  food  producer  when  the  whole  life  cycle  of 
the  animal  is  considered.  Similarly  it  has  been  estimated  by  Cooper  and 
Spillman  (Farmers'  Bulletin,  No.  877,  1917,  U.  S.  Dept.  of  Agriculture)  that 
the  crops  grown  on  a  given  area  may  be  expected  to  yield  from  four  to  five 
times  as  much  protein  and  energy  for  human  consumption  when  fed  to 
dairy  cows  as  when  used  for  beef  production. 

"Quite  recently  Dr.  Armsby  has  pointed  out  (Yale  Review,  January, 
1920)  that  'the  dairy  cow  shows  the  highest  efficiency  of  any  domestic  ani- 
mal, both  as  regards  conversion  of  food  and  availability  of  the  product  for 
men.'" 

From  studies  recently  made  by  the  Children's  Bureau  of  the  United  States 
Department  of  Labor  in  three  representative  American  cities  it  appears  that 
the  insufficiency  of  the  milk  supply  and  of  the  use  of  milk  by  children  is  wide- 
spread and  that  Cleveland  shows  no  important  difference  in  this  respect 
from  Baltimore,  Washington  and  New  Orleans. 

The  Consumers'  League  of  Ohio  has  been  so  convinced  of  the  necessity  of 
educational  propaganda  to  increase  the  use  of  milk  in  the  homes  of  Cleveland 
that  it  proposes  to  undertake  the  following  program  in  the  field  of  public 
education  during  the  summer  of  1920: 

1.  Milk  stations  will  be  installed  at  five  settlement  houses,  Woman's  City- 
Club  Food  Shop  and  public  parks  (if  possible).  These  organizations 
appear  ready  to  cooperate. 

2.  Milk  will  be  sold  to  cover  its  own  cost. 

3.  Educational  material,  posters  and  printed  matter  will  be  furnished  by 
the  Consumers'  League.  Dispensers  and  helpers  will  be  furnished  by  the 
Settlements.  Containers  and  some  other  equipment  will  be  furnished  by 
milk  companies.  Ice,  paper  cups  and  straws  are  to  be  paid  for  (it  is 
hoped)  by  the  Federation  through  funds  to  be  advanced  to  each  station. 


Tuberculosis  353 


The  Housing  Problem. 

As  stated  under  the  discussion  on  Legislation,  the  housing  regulations  are  representa- 
tive and  reasonably  complete.  Further,  no  effort  was  made  in  this  tuberculosis  survey  to 
conduct  a  field  study  of  living  conditions.  On  the  other  hand,  it  so  happens  that  a  very 
recent  study,  made  by  the  Committee  on  Housing  and  Sanitation  of  the  Cleveland  Cham- 
ber of  Commerce,  published  in  October,  1918,  covered  many  of  the  important  considera- 
tions in  the  relationship  which  housing  bears  to  disease.  This  is  a  report  which  has  been 
studied  with  some  care  and  is  recent  enough  to  be  considered  representative  of  current 
conditions.  Consequently,  certain  of  the  facts  presented  in  the  Chamber  of  Commerce 
study  will  be  reproduced  here. 

This  study  was  comprehensive  in  character,  covering  about  80,000  people  or  approxi- 
mately one-tenth  of  the  population.  It  included  the  collection  of  data  by  factory  ques- 
tionnaires, a  lodging  house  survey,  and  primarily  a  house-to-house  canvass  covering  6,292 
houses,  14,688  families,  and  69,894  individuals. 

The  reader  whose  interest  lies  in  this  direction  should  consult  the  original  report. 
We  are  in  entire  agreement  with  the  conclusions  arrived  at  and  quote  from  the  report  as 
follows: 

"First:  The  type  of  industrial  housing  in  Cleveland  is  not  as  high  as 
the  standard  set  by  the  Government  for  industrial  war  workers  and  not  as 
high  as  we  had  heretofore  believed  the  Cleveland  standard  to  be.  The 
standard  of  property  maintenance,  both  as  to  repair  and  cleanliness,  is  not 
good,  and  sanitary  equipment  is  inadequate  and  much  of  it  is  of  antiquated 
type.  There  is  unnecessary  lot  overcrowding,  the  median  percentage  of 
lot  occupied  being  seventy-seven  per  cent,  and  the  result  is  high  fire  hazard. 

"Second:  There  is  a  rapidly  increasing  tendency  on  the  part  of  our 
industrial  workers  to  live  in  tenements,  27.1  per  cent  or  more  than  one-fourth 
of  them  living  in  tenements  or  under  tenement  conditions.  There  is  also 
distinct  room  overcrowding,  50  per  cent  of  the  families  having  less  than  one 
room  per  person.  Tenement  conditions  and  overcrowding  are  two  housing 
evils  that  a  city  which  has  every  possibility  of  expansion,  both  in  territory 
and  in  transportation  facilities,  might  and  should  avoid. 

"Third:  Rents  are  not  high  in  terms  of  percentage  of  earnings  spent  in 
rent,  but  high  in  terms  of  value  received  as  so  many  of  the  houses  and  suites 
within  the  range  of  price  that  workmen  can  afford  are  old  and  in  a  poor  state 
of  repair  and  sanitation." 

With  reference  to  the  housing  situation,  a  conference  was  held  with 
Mr.  Robert  Whitten,  Director  of  the  City  Plan  Commission.  Mr.  Whitten 
stated  that  the  Building  Department  records  for  the  last  five  years  (1915 
to  1919,  inclusive)  showed  the  following  percentages  for  new  construction: 

Tenement  houses.. '. 25  per  cent 

Two-family  houses 5 1  per  cent 

One-family  houses 24  per  cent 

The  evidence  in  this  and  in  other  cities,  here  and  abroad,  tends  to  prove 
the  Value  in  prevention  of  tuberculosis  of  the  single  or  two-family  house  as 


354  Hospital  and  Health  Survey 


compared  with  tenement  blocks  or  especially  with  remodeled  houses  made 
to  serve  the  needs  of  a  number  of  families  and  their  lodgers.  It  is  from  the 
latter  type  of  adapted  residences  that  Cleveland  suffers,  particularly  in  its 
congested  Negro  and  Italian  sections. 

General  Cleanliness. 

As  stated  previously,  no  special  studies  of  general  sanitation  were  at- 
tempted. So  far  as  the  tuberculosis  is  concerned,  Cleveland  has  adequate 
legislative  machinery.  This  applies  to  milk  control,  specific  tuberculosis 
prevention'  housing,  etc.  From  the  point  of  view  of  milk,  the  practice  is 
fair.  From  the  point  of  view  of  housing,  it  is  woefully  inadequate.  It  is 
important  to  see  how  effective  may  be  the  administration  of  sanitary  legisla- 
tion along  other  lines. 

As  regards  an  item  of  vital  importance  in  anti-tuberculosis  work,  namely, 
the  enforcement  of  the  anti-spitting  ordinance,  a  little  information  is  avail- 
able. In  1917  there  were  41  convictions  for  violation  of  the  anti-spitting 
ordinance.  In  1918  there  were  seven  convictions,  and  in  1919  there  were 
no  convictions,  and  there  have  been  none  in  the  first  six  months  of  1920. 
This  would  seem  to  indicate  indifference  to  the  enforcement  of  this  measure. 
It  is  hoped  that  this  may  not  be  justified  as  an  index  of  cleanliness  and 
sanitation  along  other  lines,  such  as  food  handling,  dust  control,  fly  sup- 
pression, the  elimination  of  common  utensils,  etc.  For  further  information  on 
the  general  compliance  with  sanitary  requirements  the  reader  is  referred 
to  the  description  of  the  Division  of  Health  in  Part  II. 


Tuberculosis  355 

V. 

Special  Provisions  for  Figuring  Tuberculosis 

The  particular  resources  employed  in  Cleveland  may  be  discussed  under 
the  following  headings: 

THE  DIVISION  OF  HEALTH 

This  Division  is  a  section  of  the  Department  of  Public  Welfare,  and  is 
composed  of  a  number  of  Bureaus,  many  of  which  touch  the  tuberculosis 
problem.     These  Bureaus  may  be  briefly  described  and  discussed  as  follows: 

THE  BUREAU  OF  TUBERCULOSIS 

This  bureau  is  at  present  without  a  head,  though  a  considerable  proportion  of  the 
time  and  interest  of  the  Health  Commissioner  is  devoted  to  its  interests.  Related  to  this 
bureau,  though  not  functionally  a  part  of  it,  are  the  seven  health  centers  under  the  direc- 
tion of  the  Division  of  Health.  So  far  as  tuberculosis  work  is  concerned,  the  activities  of 
the  bureau  quite  largely  clear  through  these  outposts.  The  health  centers  are  distributed 
fairly  uniformly  throughout  the  city,  and  each  center  is  in  charge  of  a  supervising  nurse. 
A  part-time  physician  is  engaged  in  connection  with  each  center,  being  present  at  clinic 
hours.  In  three  of  these  centers  also  there  are  dental  clinics,  and  attached  to  each  center 
are  a  number  of  nurses  who  work  from  the  stations  as  a  center. 

On  the  whole,  the  work  of  these  centers  seems  to  be  worthy  of  high  commendation. 
While  developed  somewhat  rapidly  and  perhaps  a  little  haphazardly,  without  much 
reference  to  other  social  and  relief  activities  in  Cleveland,  they  do  meet  many  of  the  health 
needs  of  the  community. 

Each  station  holds  five  tuberculosis  clinic  sessions  weekly,  one  session  being  at  night. 
With  increased  personnel,  both  as  to  clinic  attendants  and  field  nurses,  the  need  for  a 
more  frequent  use  of  the  clinic  facilities  would  probably  develop.  It  is  apparently  diffi- 
cult under  the  present  arrangement  to  secure  enthusiastic  and  specially  trained  physicians 
for  tuberculosis  work  in  the  clinics.  The  men  are  for  the  most  part  young  physicians 
who  have  had  no  special  training  for  their  work.  The  work  is  part-time  and  receives 
only  part  of  their  interest  and  enthusiasm. 

The  inadequate  facilities  with  the  resulting  insufficient  uses  of  dispensaries  for  diag- 
nostic and  therapeutic  services  in  tuberculosis  in  Cleveland  is  indicated  by  comparing 
the  hours  of  special  tuberculosis  clinic  service  given  per  thousand  of  the  population  in 
Cleveland  with  service  of  a  similar  nature  offered  in  seven  other  of  the  large  cities  of  the 
country. 


356  Hospital  and  Health  Survey 


In  1920,  basing  the  service  per  100,000  upon  the  population  figures  recently  issued 
officially  by  the  Census  Bureau  as  of  January,  1920,  there  were  provided  for  the  citizens  of: 

Tuberculosis  Clinic  Hours 

of  Service  per  Week  per 

100,000  of  population 

Boston. _ _20  hours 

Philadelphia. 13  " 

New  York 10  " 

Cincinnati 10  " 

3  St.  Louis 9  " 

Cleveland 8  " 

Buffalo 6  " 

Detroit 5  " 

Under  the  Bureau  of  Tuberculosis  there  is  an  institutional  case  clerk  who  places,  by 
whatever  means  necessary,  cases  recommended  for  institutional  care.  All  cases  admitted 
to  Warrensville  are  admitted  through  the  Bureau  of  Tuberculosis,  and  unless  a  permit  is 
issued  by  the  Bureau  cases  are  refused  admission.  Before  a  case  is  sent  to  City  Hospital 
arrangements  are  made  with  the  hospital  and  a  permit  issued. 

THE  BUREAU  OF  NURSING 

At  the  present  time  there  are  approximately  80  nurses  (including  supervisors)  in  the 
Division  of  Health,  distributed  among  the  health  centers.  They  are  doing  generalized 
public  health  nursing,  and  are  looking  after  tuberculosis  work,  prenatal  work  to  a  slight 
extent,  well-baby  work,  pre-school  work  to  a  slight  degree,  parochial  school  work,  com- 
municable diseases,  boarding  homes  inspection,  trachoma,  ophthalmia,  etc. 

A  visit  to  the  health  centers,  and  particularly  to  the  teaching  center,  convinced  the 
writer  that  generalized  nursing  has  many  advantages.  From  the  point  of  view  of  the 
effectiveness  of  the  nursing  work  as  it  touches  the  tuberculosis  problem,  a  special  appraisal 
was  made  by  the  other  members  of  the  survey  staff,  particularly  concerned  with  a  study 
of  nursing  service.  These  survey  investigators  were  requested  to  comment  upon  the 
effectiveness  of  tuberculosis  nursing  from  the  following  points  of  view: 

1 .  The  efficiency  of  bedside  care. 

2.  The  interest  and  efficiency  of  the  nurses  in  finding  new  tuberculosis  cases, 
in  urging  the  families  to  come  to  the  clinics  for  examination,  etc. 

3.  The  efficiency  of  educational  work  along  the  lines  of  home  hygiene  and 
personal  hygiene. 

4.  The  adequacy  of  relief  measures. 

For  the  general  comments  on  the  nursing  situation  the  reader  is  referred  to  the  report 
on  the  nursing  work,  Part  IX.  With  special  reference  to  tuberculosis,  the  investigators 
stated  that  active  cases  were  not  visited  with  sufficient  frequency  (once  a  month  or  less 
often) ;  that  arrested  cases,  suspects,  and  contacts  were  seen  only  once  in  two  to  six  months; 
that  the  individual  nurses  have  too  many  cases  and  too  large  a  territory  to  cover;  that 
the  pressure  is  too  great  to  permit  of  much  activity  on  the  part  of  the  nurse  in  the  direc- 
tion of  finding  new  cases.  The  home  work  is  said  to  be  excellent  from  the  point  of  view 
of   securing  cooperation  from  physicians  and  others,  though  not  so  good  in  giving  specific 


Tuberculosis  .  357 

instructions  to  patients.     A  set  of  rules  to  cover  this  aspect  of  the  work  is  recommended 
by   the   nursing  investigators,  together  with  more  expert  supervision  of  the  field  work. 

While  some  public  health  representatives  in  Cleveland  seem  to  feel  that  tuberculosis 
work  has  suffered  of  late,  with  the  development  of  the  generalized  nursing  system,  on  the 
other  hand  the  general  consensus  of  opinion  seems  to  be  that  the  method  provides  many 
advantages  to  offset  its  few  defects,  even  from  the  tuberculosis  point  of  view. 

It  is  true  that  the  clinic  attendance  has  fallen  off  and  the  number  of  new  cases  annu- 
ally discovered  has  decreased  concomitant  with  the  development  of  the  generalized  system. 
However,  this  falling  off  in  clinic  attendance  in  the  past  two  years  has  been  experienced 
widely  throughout  the  country  and  presumably  does  not  reflect  the  results  of  the  nursing 
method  alone. 

THE  BUREAU  OF  STATISTICS 

The  Bureau  of  Statistics  provides  a  very  indifferent  service.  It  has  no  full-time 
chief,  and  the  methods  of  developing  statistical  data  seem  to  be  informal  and  haphazard. 
No  effort  is  made  in  tuberculosis  mortality  to  eliminate  non-resident  deaths  and  to  include 
resident  deaths  dying  out  of  town.     This  is  a  practice  which  ought  to  be  instituted. 

THE  BUREAU  OF  FOOD  AND  DAIRY  INSPECTION 

This  Bureau  has  the  responsibility  of  inspecting  food  establishments,  food  handlers, 
milk  control,  etc.  No  special  opportunity  was  afforded  for  the  determination  of  the 
effectiveness  of  this  work. 

THE  BUREAU  OF  SANITATION 

The  Bureau  of  Sanitation  has  on  its  staff  a  number  of  sanitary  officers  who  are  respon- 
sible for  the  suppression  of  nuisances,  for  housing  inspection,  etc.  The  work  of  this  bureau 
might  with  advantage  be  further  developed  and  the  standards  of  sanitary  supervision  raised 

THE  BUREAU  OF  LABORATORIES 

The  Bureau  of  Laboratories  has  charge  of  the  inspection  of  food  handlers  for  com- 
municable diseases,  sputum  examinations,  etc. 

INSTITUTIONAL  PROVISION 

The  special  provisions  made  for  the  institutional  care  of  tuberculosis 
patients  in  Cleveland  are  as  follows: 

FOR  PULMONARY  TUBERCULOSIS 

The  Warrensville  Sanatorium. 

This  is  a  city  institution  about  twelve  miles  from  the  heart  of  Cleveland,  very  attrac- 
tively located  on  the  highest  point  of  land  in  the  county.  The  equipment  makes  a  very 
pleasing  first  impression,  which  is  well  sustained  by  further  contact.  The  general  man- 
agement of  the  institution,  including  the  records,  etc.,  seems  first  class. 

The  equipment  includes  an  excellent  laboratory,  an  X-Ray  plant,  facilities  for  pneu- 
mothorax operations,  a  nose,  throat,  ear  and  eye  room,  dental  equipment  with  full-time 
resident  dentist,  etc.  There  are  four  or  five  physicians  on  the  staff,  the  physician  in 
charge  being  a  graduate  of  Western  Reserve  University,  and  of  the  special  course  at  Tru- 


358 


Hospital  and  Health  Survey 


1.  Only  available  playground  space  in  an  overcrowded  district. 

2.  Flashlight  photograph   of  dark  passageway  between  two  te: 
earms  of  flies. 

3.  Typical  of  many  homes  in  the  Haymarkct  district.     Sanitation  unheard  of  here. 


2.     Flashlight   photograph    of  dark   passageway   between   two  tenements.      Rotting  garbage  and  filth  here  attract 
swarms  of  flies. 


Tuberculosis 


359 


$8% 


>■  ■■■•■  ■ 


Warrensville 
Tuberculosis 
Sanatorium 

where  the 

"tuberculosis 

patients 


360  Hospital  and  Health  Survey 

deau.  This  institution  has  a  capacity  of  254  beds  for  pulmonary  tuberculosis,  a  number 
of  beds  being  vacant  at  the  time  of  visit.  Most  of  the  cases  are  moderately  advanced, 
and  a  few  far  advanced.  This  admission  of  advanced  cases  in  an  institution  that  is  sup- 
posed to  care  for  early  cases  is  unfortunate  from  many  points  of  view.  It  tends  to  increase 
the  mortality  of  the  institution  and  to  make  comparisons  between  it  and  other  sanatoria 
unfavorable  from  the  point  of  view  of  Cleveland.  It  tends  to  give  the  institution  a  local 
reputation  for  having  a  high  mortality,  and  to  increase  the  unwillingness  on  the  part  of 
patients  to  be  hospitalized. 

The  Commissioner  of  Health  stated  that  a  large  percentage  of  the  patients  left  against 
advice,  though  only  a  few  because  of  genuine  dissatisfaction.  He  stated  that  the  average 
length  of  stay  had  been  increased  from  three  months  in  1913  to  six  and  a  half  months  in 
1918. 

Those  in  charge,  under  the  direction  of  the  Health  Commissioner,  have  developed  an 
excellent  method  of  grading  patients  at  Warrensville  on  the  basis  of  their  ability  to  take 
exercise,  the  work  merging  into  occupational  therapy.  Patients  are  graded  all  the  way 
from  active  bed  patients  to  those  in  an  arrested  stage,  and  followed  up  by  occupational 
service.  The  plan  seemed  to  be  unique  and  very  desirable,  and  its  operation  effective. 
Somewhat  comparable  to  this  occupational  therapy  system  is  the  current  classification 
chart  in  use  at  the  sanatorium  for  patients  of  all  types.  This  was  devised  by  Dr.  Frye, 
the  resident  physician  in  charge,  and  should  be  given  wide  publicity,  for  it  is  a  device 
which  would  be  useful  for  many  institutions.  This  chart,  by  a  series  of  colors,  shows  at 
a  glance  for  each  ward  the  beds  occupied,  the  vacancies,  the  age,  stage  on  admission,  pres- 
ent condition,  sputum  findings,  etc.,  for  each  case.  The  institution  deserves  much  com- 
mendation for  the  maintenance  of  this  system.  From  the  point  of  view  of  the  future 
working  adjustment  of  the  patient,  it  would  be  well  to  develop  at  this  institution  a  system 
of  special  vocational  training.  This  might  well  be  looked  upon  as  an  economic  obligation 
which  the  institution  owes  to  the  individuals  under  its  charge. 

The  Ohio  State  Sanatorium. 

This  institution  provides  approximately  23  beds  for  Cleveland  cases,  of  the  early 
pulmonary  type. 

The  City  Hospital. 

This  institution  provides  100  beds  for  advanced  pulmonary  tuberculosis,  84  of  which 
are  for  men  and  16  for  women.  The  tuberculosis  ward  is  situated  on  the  edge  of  a  deep 
valley,  overlooking  a  number  of  industrial  plants,  and  is  exposed  to  a  great  deal  of  dust 
and  smoke.  At  the  time  of  the  visit  there  were  only  70  patients  in  the  hospital,  the  empty 
beds  being  all  on  the  male  side.  It  was  stated  that  the  average  length  of  stay  is  approxi- 
mately one  year,  though  some  patients  have  been  there  six  or  seven  years.  Two  patients 
were  being  held  under  compulsory  segregation. 

This  institution  comes  in  for  a  great  deal  of  criticism  with  reference  to  food,  nursing, 
medical  care,  general  attention,  etc.  How  much  of  it  is  justified  is  difficult  to  say.  Cer- 
tainly in  physical  equipment  and  general  appearance,  the  building  used  by  the  tuberculosis 
patients  has  nothing  to  recommend  it  and  should  be  replaced. 

State  Insane  Hospital. 

This  institution  provides  approximately  6  beds  for  advanced  pulmonary  disease  from 
Cleveland. 


Tuberculosis  361 

Other  General  Hospitals. 

A  sickness  census  of  the  other  hospitals  of  Cleveland  at  the  time  of  the  survey  indi- 
cated that  there  were  perhaps  ten  or  a  dozen  cases  of  advanced  pulmonary  disease  in  the 
general  hospitals  of  the  city. 

FOR   NON-PULMONARY    TUBERCULOSIS,    ARRESTED   DISEASE,   PRE- 
VENTORIUM CARE,  CLOSED  CASES  AMONG  CHILDREN,  ETC. 
The  Warrensville  Children's  Camp. 

This  camp  is  adjacent  to  the  sanatorium  at  Warrensville,  and  has  provision  for  30 
children.  The  provision  is  inadequate  and  the  equipment  could  readily  be  expanded  to 
provide  for  at  least  50  cases. 

The  Rainbow  Hospital. 

This  institution  cares  for  an  average  of  40  non-pulmonary  or  arrested  cases  among 
children,  chiefly  orthopedic  convalescents. 

The  Home  for  Crippled  Children. 

This  institution  has  provision  for  about  25  cases  of  non-pulmonary  tuberculosis. 
The  Fresh  Air  Camp. 

This  institution  offers  preventorium  advantages  for  approximately  30  children  through- 
out the  year  and  occasionally  takes  discharged  children  from  the  Warrensville  institution. 

There  are,  in  addition  to  this  camp,  a  number  of  others  for  preventorium  care  in 
Cleveland.  All  told  there  are  12  or  more  summer  camps  for  children  and  mothers  with 
a  capacity  of  over  a  thousand  beds.  These  activities  were  for  the  first  time  correlated 
during  the  summer  of  1919,  by  the  Cleveland  Welfare  Federation. 

To  summarize  the  bed  facilities,  the  situation  may  be  indicated  as  follows: 
For  Pulmonary  Disease 

Warrensville  Sanatorium 254  beds 

State  Sanatorium _ _ 23     " 

City  Hospital _ 100     " 

Insane  Hospital ._ 6     " 

General  Hospitals _ 10     " 

Total #-393  beds 

For  Non-Pulmonary  Disease. 

Warrensville  Camp 30  beds 

Rainbow  Hospital ._ 40      " 

Home  for  Crippled  Children 25      " 

Fresh  Air  Camp __ _  30     " 

Total _ _ 125  beds 

Grand  Total 518     " 


362  Hospital  and  Health  Survey 

While  at  the  present  time  many  of  the  beds  in  Cleveland  are  unoccupied, 
it  was  only  a  year  or  two  ago  that  patients  had  to  wait  five  months  or  more 
for  admission.  This  lack  of  insistent  demand  for  bed  facilities  at  the  present 
time  is  quite  characteristic  of  national  conditions,  and  is  presumably  tem- 
porary. 

As  a  matter  of  fact  it  seems  to  be  an  unanimous  opinion  in  Cleveland 
that  there  are  many  urgent  needs  for  increased  bed  capacity.  The  most 
conspicuous  of  these  may  be  briefly  listed.  They  will  be  mentioned  again 
in  somewhat  more  detail  subsequently.     (See  Part  X.) 

1.  Beds  for  early  pulmonary  adult  cases. 

2.  Beds  for  advanced  pulmonary  adult  cases. 

3.  Beds  for  open  pulmonary  childhood  cases. 

'  4.  Beds  for  surgically  convalescent  adult  cases. 

5.  Beds  for  complicated  adult  cases,  such  as  in  pregnancy. 

6.  Beds  for  exposed  early  non-pulmonary  cases  among  children  from  birth 
to  five  years  of  age. 

7.  Beds  for  closed  childhood  cases. 

8.  Possibly  beds  for  relatively  well-to-do,  able-to-pay  patients. 

OTHER  ORGANIZATION  COMMUNITY  MEASURES 

The  Department  of  Education.     (See  Part  III.  for  details.) 

This  department  has  one  full-time  physician  on  its  staff,  and  employs  25  physicians 
on'part-time.  The  department  has  a  supervisory  nurse  and  30  field  nurses.  It  also  has 
six  dentists  and  six  dental  hygienists.  Several  eye  clinics  are  in  operation  and  a  system 
of  physical  education  is  carried  out.  Twenty  open  air  schools  for  under-par  children, 
with  morning  and  afternoon  feeding,  are  conducted.  There  are  at  the  present  time  also 
two  nutrition  classes  in  the  Cleveland  schools.  Further,  it  was  stated  that  one  of  the 
physicians  on  the  part-time  service  had  had  special  tuberculosis  training  and  acted  in  a 
measure  as  a  consultant  for  the  other  physicians. 

The  Anti-Tuberculosis  League. 

In  the  past  the  Anti-Tuberculosis  League  of  Cleveland  has  seized  the  opportunity  to 
make  Cleveland  a  city  with  recognized  leadership  in  tuberculosis  work.  Most  of  the  tuber- 
culosis activities  that  are  now  carried  on  in  Cleveland  by  official  or  private  agencies  were 
a  result  of  the  initiative  and  constructive  energy  of  the  League. 

At  the  present  time  the  League  is  somewhat  at  a  stand-still  in  its  active  program.  It 
is  subsidizing  other  agencies  quite  generously.  With  the  funds  at  its  disposal  it  is  giving 
financial  aid  to  the  teaching  district.  It  is  financing  the  health  crusade  movement  in 
Cleveland,  under  the  agency  of  the  State  Tuberculosis  League.  It  is  responsible  for  the 
excellent  system  of  occupational  therapy  and  follow-up  in  connection  with  the  Warrens- 
ville  Sanatorium. 


Tuberculosis  363 


The  chief  field  for  the  League  should  lie  along  educational  lines.  However,  during 
the  past  few  years  very  little  has  been  done  in  this  field  by  any  agencies  in  Cleve- 
land. An  educational  campaign  should  be  mapped  out,  a  campaign  which  would  fall 
primarily  to  the  League  for  execution.  It  is  understood  that  the  League  has  adequate 
financial  resources,  through  the  Welfare  Federation  and  as  a  result  of  the  sale  of  Red  Cross 
Seals,  which  would  make  possible  a  genuine  up-to-date  educational  program. 

Charities,' 

The  Associated  Charities  of  Cleveland  is  said  to  be  one  of  the  best  organizations  of 
this  kind  in  the  country.  It  employs  45  field  workers,  who  operate  in  close  cooperation 
with  the  health  centers  and  the  nurses  doing  tuberculosis  work.  There  is  also  operated 
what  appears  to  be  an  efficient  case  clearing  house.  The  Associated  Charities  is  supple- 
mented by  Jewish  and  Catholic  charities  as  well.  The  districts  employed  by  the  charitable 
organizations  in  Cleveland  in  no  way  coincide  with  the  health  center  districts. 

Industrial  Medical  Work,     (See  special  report  on  Industrial  Medical  Service,  Part  VII.) 

The  medical  work  in  the  industries  of  Cleveland  is  at  the  present  time  very  inade- 
quately developed.  While  there  are  several  part-time  physicians  and  a  large  body  of 
nurses  engaged  in  this  work,  there  is  no  special  tuberculosis  work,  very  little  routine  medi- 
cal examining,  and  an  inadequate  program  for  health  and  anti-tuberculosis  education. 

A  thorough  system  of  educational  work  in  industry  should  be  developed.  This  would 
be  a  legitimate  activity  for  the  Anti-Tuberculosis  League.  A  plan  should  be  mapped  out 
somewhat  similar  to  the  recently  proposed  program  of  the  New  York  City  Tuberculosis 
Association.  This  calls  for  a  campaign  to  secure  the  cooperation  of  the  Chamber  of  Com- 
merce, and  the  manufacturers'  associations,  noon-day  special  talks  to  the  men  in  the  fac- 
tories, the  distribution  of  literature  to  industrial  workers  in  their  shops,  the  organization 
of  shop  sanitation  committees,  the  development  of  sentiment  and  demand  for  medical 
examination  in  industry,  the  establishment  of  model  examining  rooms  for  tuberculosis 
work,  the  development  of  exhibits  for  use  in  industrial  establishments,  etc. 

The  Red  Cross,  the  Consumers*  League  and  other  private  agencies. 

Through  these  organizations,  particularly  the  Red  Cross,  a  number  of  demonstration 
and  lecture  courses  in  home  nursing,  home  economics,  infant  care  and  feeding,  and  home 
sanitation  and  personal  hygiene  are  offered.  Interpreters  are  used  for  foreign  groups, 
diplomas  and  pins  are  given  for  satisfactory  attendance. 


364  Hospital  and  Health  Survey 

VI. 
A  Summary  of  Activities   ana  Equipment 

ON  the  basis  of  the  foregoing  material  an  attempt  will  be  made  to  present 
a  brief  summary  of  the  methods  used  and  equipment  developed  to  fight 
tuberculosis  in  Cleveland.     The  situation  may  be  summarized  under 
certain  conspicuous  headings,  the  first  of  which  is: 

THE  PREVENTION  OF  TUBERCULOSIS 

Tuberculosis  is,  first,  an  almost  universal  infection;  second,  an  extensive  disease; 
and  third,  a  prominent  cause  of  mortality.  It  is  possible  to  take  measures  to  prevent 
the  infection,  to  prevent  or  arrest  the  active  disease,  and  to  prevent  or  postpone  mortality. 
It  is  necessary,  in  fact,  to  consider  the  problem  of  prevention  from  these  three  points  of 
view: 

The  Prevention  of  Infection. 

Infection  is  acquired  through  contact  with  sick  individuals,  through 
sputum,  through  infected  milk,  or  through  intermediate  contact  by  means 
of  common  utensils,  etc. 

To  prevent  unnecessary  exposure  by  direct  contact  between  sick  and 
well  individuals  is  largely  a  matter  of  education  in  personal  hygiene.  This 
is  a  field  that  has  been  only  slightly  developed  in  Cleveland,  and  should  be 
considered  a  major  activity  for  the  immediate  future.  The  segregation  of 
dangerous  cases  of  open  tuberculosis  is  another  matter  of  extreme  importance. 
Cleveland  has  legislation  for  the  control  of  incorrigible  consumptives,  but  uses 
it  only  rarely.     It  is  probable  that  its  use  could  be  materially  increased. 

The  control  of  sputum  transmission  is  a  matter  of  sanitary  law  enforce- 
ment and  education.  Both  the  enforcement  of  sputum  ordinances  and  the 
education  of  the  public  about  the  dangers  of  sputum  are  at  present  much 
neglected. 

In  the  matter  of  milk  control  Cleveland  seems  to  be  meeting  the  situation 
with  only  fair  success. 

In  the  matter  of  the  suppression  of  common  utensils,  no  direct  data  are  at 
hand.  This,  of  course,  is  largely  a  matter  of  education  in  personal  hygiene, 
through  schools,  factories,  and  among  the  general  public,  and  it  must  be 
admitted  that  much  remains  to  be  done  along  that  line  in  Cleveland.  There 
is  also  involved  here  the  essential  equipment  for  proper  living,  such  as  ade- 
quate and  hygienic  equipment  in  housing.  We  have  seen  that  the  situation 
in  Cleveland  in  this  regard  is  in  many  respects  deplorable. 

The  Prevention  of  Disease. 

If  infection  cannot  be  prevented,  what  measures  can  be  taken  to  prevent 
disease?     How  adequately  are  these  measures  developed  in  Cleveland? 

The  incidence  of  active  disease,  upon  the  basis  of  almost  universal  infec- 
tion, is  a  matter  of  individual  break-down  under  some  form  or  combination 


Tuberculosis  365 


of  stress  or  strain,  physical  or  mental.  This  strain,  of  course,  is  most  preva- 
lent in  the  younger  age  groups,  particularly  in  the  industrial  period.  It  is 
there  that  we  find  the  greatest  economic  handicap  from  tuberculosis  disease. 
To  combat  this  factor  in  industry,  there  is  needed  an  aggressive  campaign 
of  industrial  hygiene,  and  this  is  yet  to  be  developed  in  Cleveland.  It 
means  education  in  industrial  sanitation,  of  employers  and  employes.  It 
means  the  establishment  of  adequate  medical,  nursing  and  clinical  facilities 
and  personnel  in  industry.  It  means  the  routine  regular  examination  of 
industrial  employes  to  detect  the  beginning  of  signs  of  disease.  It  means 
the  consistent  and  thorough  occupational  and  educational  follow-up  of 
arrested  cases  of  disease  as  they  return  to  industrial  pursuits. 

The  prevention  of  disease  is  also  a  matter  of  increasing  individual 
resistance,  as  well  as  reducing  the  factors  of  strain.  This  means  general 
education  along  the  line  of  constructive  hygiene.  It  means  the  promotion 
of  home  hygiene.  It  involves  the  development  of  various  preventorium 
activities,  such  as  summer  camps,  etc.  It  implies  a  campaign  to  improve 
food  habits  and  particularly  to  increase  milk  consumption.  In  the  matter 
of  summer  camps  and  preventorium  facilities,  particularly  for  children, 
Cleveland  seems  reasonably  well  equipped.  Something  is  being  done  by  the 
Red  Cross  and  other  agencies  in  the  matter  of  home  hygiene.  Very  little  is 
being  done  for  the  general  population  in  the  matter  of  hygienic  education. 
Finally,  the  situation  with  reference  to  food  hygiene,  and  particularly  milk 
consumption,  is  serious. 

This  latter  problem,  of  course,  is  not  only  one  of  increasing  milk  de- 
mand but  also  of  increasing  milk  supply.  It  is  a  matter  which  deserves  the 
serious  consideration  of  all  interested  in  the  welfare  of  Cleveland,  and  is  an 
economic  as  well  as  nutritional  problem.  It  is  possible  that  eventually  the 
solution  of  this  problem  in  municipalities  will  be  found  in  the  field  of  the 
socialization  of  city  milk  supplies. 

The  Prevention  of  Unnecessary  Mortality. 

This  is  in  large  measure  a  matter  of  improved  therapeutic  practice.  It 
means  the  popularization  of  adequate  treatment  measures,  the  enhancement 
of  institutional  methods,  or  increased  institutionalization  of  active  tubercu- 
losis disease.  For  Cleveland  it  means  an  aggressive  educational  campaign 
to  popularize  and  stabilize  the  use  of  existing  sanatorium  and  hospital  equip- 
ment, and  it  will  mean  eventually  an  increase  in  that  equipment.  An  exten- 
sive, popular  educational  campaign  might  do  much  to  increase  the  willingness 
of  patients  to  come  to  the  institutions,  and  to  hold  them  there  once  they  are 
hospitalized.  Probably  consistently  high  grade  professional  service  for  the 
sick  will  be  the  most  effective  solicitor  for  the  use  of  Warrensville  for  early 
cases  of  tuberculosis. 

THE  DETECTION  OF  TUBERCULOSIS 

As  pointed  out  previously,  the  amount  of  known  tuberculosis  in  Cleveland  in  ratio 
to  deaths  is  at  least  up  to,  and  perhaps  above,  the  average  for  other  American  municipali- 
ties. The  nursing  and  health  center  organization  is  certainly  of  an  advanced  type,  and 
Cleveland  is  to  be  congratulated  upon  the  progress  that  has  been  made  in  that  field,  and 
upon  the  example  which  the  city  sets  for  other  municipalities. 


366  Hospital  and  Health  Survey 

On  the  other  hand,  when  measured  by  theoretical  standards  of  probable  tuberculosis 
incidence,  the  actual  ratio  of  reported  cases  to  deaths  (4.7  to  1)  is  low.  Nine  or  ten  cases 
to  every  annual  death  should  be  under  observation  or  treatment. 

The  percentage  of  early  cases  (approximately  50  per  cent)  of  the  total  cases  reported 
is  low,  as  compared  with  what  may  be  accomplished  with  special  machinery  for  the  detec- 
tion of  tuberculosis  (Framingham — 74  per  cent). 

The  percentage  of  cases  reported  before  death  (75  per  cent  or  less)  is  also  low.  (Fram- 
ingham— 94  per  cent). 

As  supplementary  equipment  to  the  nursing  and  health  center  work,  to  the  medical 
work  in  schools,  and  to  a  certain  extent  in  the  infant  clinics,  Cleveland  needs  much  addi- 
tional routine  medical  and  disease  detecting  machinery,  particularly  in  the  field  of  indus- 
try. Further,  the  discovery  of  tuberculosis  could  be  greatly  enhanced  by  the  establish- 
ment of  some  form  of  advanced  diagnostic  training  for  the  physicians  in  the  clinics  and  in 
general  practice,  and  particularly  by  the  establishment  of  an  expert  consultation  service 
working  for  the  detection  of  disease,  through  the  health  centers,  and  with  the  general 
practising  physicians  in  the  city. 

THE  TREATMENT  OF  TUBERCULOSIS 

As  might  be  pointed  out  Cleveland  is  at  the  bottom  of  the  list  of  a  number  of  com- 
parable American  cities  in  the  ratio  of  tuberculosis  beds  to  population.  The  investiga- 
tion, and  the  numerous  conferences  with  leaders  in  tuberculosis  work  in  Cleveland  have 
emphasized  that  there  is  at  present  pressing  need  for  institutional  provision  for  the  many 
types  of  tuberculosis  patients. 

On  the  basis  of  experience  elsewhere,  it  has  been  accepted  that  each  community 
should  provide  at  least  one  bed  for  every  annual  death  from  tuberculosis.  Cleveland 
averages  from  1,000  to  1,200  annual  deaths  and  now  has  available  518  beds  for  pulmonary 
and  non-pulmonary  disease.  This  means  that  to  meet  the  minimum  requirements,  the 
existing  facilities  should  be  approximately  doubled. 

The  nursing  work,  while  of  importance  in  disease  detection,  is  of  primary  signifi- 
cance in  treatment.  The  generalized  system  seems  to  work  with  fair  advantage  in  meet- 
ing the  tuberculosis  problem.  On  the  other  hand,  the  present  supply  of  nurses  is 
inadequate. 

There  are  80  nurses  provided  by  the  Division  of  Health,  approximately  32  nurses 
doing  district  nursing  for  the  Visiting  Nurse  Association,  31  school  nurses  of  the  Board 
of  Education,  and  a  variable  number  of  student  public  health  nurses  in  the  University 
District  estimated  as  equalling  10  nurses  in- amount  of  service  rendered.  This  gives  a 
total  of  153  nurses  available  for  public  health  nursing  in  Cleveland.  Over  one  hundred 
more  are  needed. 

It  is  estimated  that  it  requires  at  least  one  nurse  for  every  3,000  of  the  population 
(some  authorities  estimate  one  to  2,000  of  population)  to  cover  all  the  needs  of  the  popula- 
tion in  the  generalized  system. 

By  the  generalized  system  is  meant  a  system  by  which  the  city  is  divided  into  small 
districts,  one  nurse  to  each  district  and  the  one  nurse  doing  all  kinds  of  nursing  and  instruc- 
tion in  health  in  that  district.     In  no  large  city  has  a  completely  generalized  system  been 


Tuberculosis 


instituted;  in  Cleveland  generalization  has  reached  the  point  of  concentrating  all  public 
health  nurses  in  three  agencies.  These  agencies  again  have  generalized  their  activities 
by  having  one  nurse  in  each  district  carry  on  all  services  which  the  agency  offers.  In  the 
University  District  generalization  is  carried  farther,  the  school  nurses  being  the  only 
separate  group. 

It  is  also  probable  that  treatment  could  be  improved  by  supplying  more  adequate 
specialized  supervision.     This  is  essential  where  generalized  nursing  is  employed. 

Material  relief  is  of  vital  importance  in  the  treatment  of  many  tuberculosis  patients 
and  seems  to  be  on  the  whole  adequate.  This  is  the  opinion  of  the  Division  of  Health 
workers,  as  well  as  of  the  Associated  Charities.  On  the  other  hand,  certain  of  the  nurses 
seem  to  feel  that  it  is  difficult  to  get  from  the  Relief  Organizations  an  adequate  budget 
for  food  for  tuberculosis  families.  It  is  quite  evident  from  the  milk  study  that  while  the 
relief  families  are  a  little  better  off  on  milk  supply  than  the  non-relief  families,  they  are 
receiving,  nevertheless,  a  milk  supply  which  falls  short  by  nearly  50  per  cent  of  being 
adequate  to  meet  the  family  needs.  This  is  a  situation  which  should  be  recognized  and 
met. 

The  conditions  at  the  Warrensville  Sanatorium  do,  of  course,  bear  an  important  rela- 
tion to  treatment.  Much  has  been  done  in  a  practical  way  during  the  last  year  or  two^to 
improve  the  situation  there.  Heating  arrangements  have  been  perfected  and  improve- 
ments made  in  the  food  supply.  Those  in  charge  have  also  been  successful  in  increasing 
the  average  stay  of  patients,  the  figure  now  being  six  and  one-half  months.  This  compares 
favorably  with  other  institutions  of  similar  character.  For  instance,  at  the  Maryland 
Tuberculosis  Sanatorium  in  1917  the  average  stay  was  five  and  one-sixth  months.  The 
war  industrial  developments  since  then  must  have  tended  to  reduce  that  figure  rather 
than  to  have  increased  it. 

FOLLOW-UP  METHODS 

An  effort  is  being  made  in  Cleveland  by  the  Anti-Tuberculosis  League  to  follow  up 
cases  being  discharged  from  or  leaving  the  sanatorium.  The  secretary  in  charge  of  this 
work,  endeavors  to  find  employment  for  arrested  cases,  through  the  Chamber  of  Com- 
merce Employment  Managers  Group,  the  City  Employment  Office,  the  Division  of 
Labor,  the  Negro  Welfare  League,  the  Y.  M.  C.  A.,  etc.  He  endeavors  to  follow  up  all 
Warrensville  cases,  but  is  of  course  by  no  means  always  successful.  He  was  successful  in 
1918  in  placing  24  cases  in  satisfactory  occupations.  This,  however,  was  only  a  small 
percentage  of  the  total  cases  leaving  the  institution.  For  instance,  for  the  period  of  one 
year  135  males  alone  left  the  institution. 

Of  all  the  cases  that  do  leave  and  are  classified  as  arrested,  it  is  essential  that  they 
be  followed  up  for  at  least  a  year  to  determine  the  degree  of  satisfactoriness  with  which 
they  are  making  an  industrial  and  social  re-adjustment.  It  is  customary  in  Cleveland 
to  drop  arrested  cases  after  an  observation  period  of  six  months.  From  the  point  of  view  of 
follow-up,  this  time  could  with  advantage  be  extended. 

The  percentage  actually  leaving  the  Warrensville  institution  is  in  a  sense  a  measure 
of  the  need  for  follow-up,  and  is  also  a  measure  of  the  effectiveness  of  treatment.  On  the 
male  side  alone  during  a  recent  annual  period  135  left  the  institution,  59  of  whom  were 
unimproved.  This  is  44  per  cent  of  the  total  and  seems  like  a  high  percentage.  In  reality 
it  does  not  compare  very  unfavorably  with  other  institutions  for  which  similar  figures  are 


.368  Hospital  and  Health  Survey 

available.  At  the  Raybrook  Sanatorium  in  New  York  State,  for  instance,  in  1917,  of  the 
patients  admitted  as  incipient,  5.5  per  cent  left  unimproved;  of  those  admitted  as  moder- 
ately advanced  33.8  per  cent  left  unimproved;  of  those  admitted  as  advanced  61.9  per 
cent  left  unimproved.  It  is  probable  that  this  figure  of  33.8  for  Raybrook's  moderately 
advanced  cases  is  in  a  genuine  sense  comparable  with  the  Warrensville  percentage  of  44. 
It  is  probable  that  most  of  the  cases  admitted  at  Warrensville  are  in  a  moderately  ad- 
vanced state  when  institutionalized,  even  though  the  institution  was  designed  as  a  place 
for  the  treatment  of  incipient  disease.  Such  it  should  be,  but  it  is  not  at  present.  Cer- 
tainly an  energetic  effort  should  be  made,  not  only  to  institutionalize  more  early  cases, 
but  also  to  reduce  the  percentage  leaving  in  an  unimproved  condition. 

Finally,  with  reference  to  Warrensville,  it  may  be  said  that  the  "case  bookkeeping" 
at  the  institution  is  admirable.  The  quality  of  the  professional  records  as  to  examinations, 
and  appended  notes,  is  all  that  could  be  desired. 

EDUCATION  AGAINST  TUBERCULOSIS 

Much  has  been  said  already  about  education  under  the  headings  Prevention,  Detec- 
tion, Treatment,  etc.  Educational  measures  against  tuberculosis  in  Cleveland  are  for  the 
most  part  lacking  at  present.  Much,  in  fact,  should  be  done  by  the  League  and  by  other 
agencies  to  fill  this  lamentable  gap  in  the  Cleveland  bulwarks  against  disease.  Very  little 
special  educational  work  is  being  carried  out  against  infection,  against  disease,  or  against 
premature  death.  Very  little  educational  work  is  being  done  in  industry.  Special  efforts 
at  education  are  needed  to  increase  the  effectiveness  of  the  existing  diagnostic  and  treat- 
ment facilities. 

TUBERCULOSIS  RESEARCH  AND  TEACHING 

At  the  present  time  there  is  in  Cleveland  very  little  opportunity  for  special  research 
in  tuberculosis  work.  This  applies  to  laboratory  as  well  as  social  research.  There  is 
need  of  a  special  experimental  demonstration  along  the  lines  of  disease  detection  and 
control  and  there  is  an  excellent  opportunity  for  such  work  in  the  established  health  dis- 
tricts. 

While  Cleveland  possesses  an  excellent  medical  school,  very  little  advantage  is  taken 
of  the  equipment  and  personnel  to  enhance  the  knowledge  of  tuberculosis  among  the 
medical  profession  in  general.  No  post-graduate  work  is  offered  in  tuberculosis  at  this 
institution.  No  special  training  is  provided  for  the  physicians  engaged  in  the  health 
centers.  No  special  opportunities  for  training  and  for  consultation  are  offered  to  the 
general  practitioners.  All  of  these  might  legitimately  be  expected  from  a  medical  institu- 
tion of  the  standing  of  Western  Reserve  University. 

ANTI-TUBERCULOSIS  ORGANIZATION 

The  establishment  of  the  Bureau  of  Tuberculosis  in  the  Division  of  Health  was  a 
great  step  in  advance.  However,  to  realize  the  full  advantages  of  this  measure  this  Bureau 
should  be  given  a  full-time  chief.  The  Bureau  should  be  brought  into  closer  relation  with 
the  medical  school,  for  teaching  purposes  at  least. 


Tuberculosis  369 

Other  obvious  needs  in  organization,  if  the  tuberculosis  situation  is  adequately  to  be 
met,  include  improved  statistical  work  in  the  Division  of  Health,  modifications  in  the 
system  of  case  bookkeeping,  the  extension  of  the  program  and  personnel  of  the  Anti- 
Tuberculosis  League,  a  closer  inter-relation  between  the  League,  the  Bureau  of  Tubercu- 
losis and  the  medical  school,  etc. 


370  Hospital  and  Health  Survey 

VII. 

Recommendations 

THE  foregoing  analysis  of  tuberculosis  work  in  Cleveland  has  indicated 
that  in  many  respects  Cleveland  is  to  be  congratulated  upon  the  admir- 
able way  ii  which  the  public  and  private  agencies  have  pushed  forward 
the  organization  and  program  for  combating  this  disease. 

The  report  has  also  indicated  that  the  chief  deficiencies  in  the  tubercu- 
losis machinery  at  the  present  time  are  in  the  fields  of  tuberculosis  detection, 
treatment,  education,  organization  and  general  sanitation. 

In  summarizing  the  conclusions  and  recommendations  made  in  various 
sections  of  the  foregoing  report,  the  particular  suggestions  which  seem 
worthy  of  special  consideration  are  as  follows : 

ADDITIONAL  MACHINERY  FOR   THE  DETECTION  OF  TUBERCULOSIS 

To  supplement  the  existing  machinery  for  disease  detection  we  would,  on  a  basis  of 
the  report,  recommend  the  following  supplementary  measures: 

A  Post -Graduate  Training  Course  in  Tuberculosis. 

This  course  should  presumably  be  organized  at  the  Medical  School, 
though  its  actual  operation  might  be  carried  out  in  cooperation  with  the 
Bureau  of  Tuberculosis  or  the  Anti-Tuberculosis  League,  or  both  agencies. 

In  its  curriculum  it  should  emphasize  the  medical  problem  of  diagnosis, 
classification  and  treatment. 

If  a  general  diagnostic  medical  center  is  established,  it  might  be  operated 
in  close  cooperation  with  such  an  agency. 

The  courses  should  be  open  to  the  general  practitioners  in  Cleveland  and 
elsewhere,  and  should  be  made  compulsory  for  the  physicians  serving  in  the 
health  centers.  Should  the  Medical  School  wish  to  establish  such  a  service, 
active  cooperation  could  be  secured  from  the  Medical  Department  of  the 
National  Tuberculosis  Association. 

An  Expert  Consultation  Service. 

Such  a  service,  on  tuberculosis,  should  be  established  either  by  the  Bureau 
of  Tuberculosis  or  by  the  Anti-Tuberculosis  League,  working  in  close  coopera- 
tion with  the  Medical  School. 

This  might  be  at  the  start  either  a  general  service  covering  all  sections 
of  the  city,  or  perhaps  preferably  a  special  demonstration  service,  concentrat- 
ing in  one  health  district,  and  working  with  the  physicians  of  that  district, 
through  the  center. 

This  service  should  be,  in  the  first  place,  for  the  clinic  physicians,  but 
should  gradually  be  extended  through  the  clinics  to  the  physicians  in  the 
neighborhood. 


Tuberculosis  371 

Such  a  consultation  service  may  be  counted  upon  to  do  the  following 
things  for  tuberculosis  detection  in  Cleveland:  It  will  increase  the  number 
of  cases  under  care.  In  Framingham,  Massachusetts,  it  helped  materially 
to  increase  the  number  from  27  to  200.  It  will  increase  the  percentage  of 
early  cases  under  care.  In  Framingham,  Massachusetts,  it  assisted  materi- 
ally in  increasing  this  percentage  from  46  to  74.  The  percentage  of  early 
cases  in  Cleveland  at  present  is  approximately  50.  It  will  increase  the  num- 
ber of  cases  cared  for  in  institutions.  In  Framingham,  Massachusetts,  this 
percentage  was  increased  from  20  to  33  per  cent.  It  will  help  to  increase 
reporting.  In  Framingham,  Massachusetts,  the  consultation  service  and 
other  activities  quadrupled  reporting  over  previous  experience.  It  will 
serve  as  an  excellent  basis  for  medical  education,  being  in  itself  a  constantly 
operating  post-graduate  instruction  course. 

The  consultation  service  acts  as  a  triple  link  in  the  community,  connect- 
ing up  the  patient  and  the  doctor  for  early  diagnosis,  the  patient  and  treatment 
facilities,  and  the  doctor  and  scientific  knowledge. 

Routine  Work  Among  Infants,  in  Schools,  in  Factories. 

While  the  consultation  service  is  the  most  valuable  single  measure  for  the 
detection  of  tuberculosis,  to  be  effective  it  should  be  supplemented  by  routine 
medical  work  in  schools,  factories  and  elsewhere.  The  consultant  may  act 
in  his  special  capacity  with  as  great  advantage  for  the  ordinary  physician  in 
school  and  factory  work  as  for  the  private  practitioner. 

As  has  been  pointed  out  in  the  report,  there  is  a  glaring  need  for  adequate 
full-time  medical  examination  and  nursing  work  in  the  industries  of  Cleve- 
land. While  the  school  work  is  relatively  adequate,  there  is  an  undeveloped 
field  in  prenatal  care  and  among  children  of  pre-school  age. 

ADDITIONAL  TREATMENT  FACILITIES 

This  report  has  indicated  that  there  are  at  present  393  beds  for  pulmonary  tubercu- 
losis, and  125  beds  for  non-pulmonary  tuberculosis,  making  a  total  of  518  available  beds 
in  Cleveland.  It  has  also  been  stated  that  there  should  be  in  Cleveland  approximately 
one  bed  for  every  annual  death,  which  at  a  minimum  would  mean  one  thousand  beds. 
The  report  has  also  discussed  those  elements  in  the  population  and  those  forms  of  the 
disease  which  most  need  increased  bed  facilities.  These  needs  might  be  summarized  as 
follows : 

Increased  capacity  for  early  cases.  It  is  estimated  that  at  least  200 
beds  for  early  cases  should  be  added  to  the  Warrensville  equipment.  A 
concentration  upon  the  discovery  of  tuberculosis  will  soon  more  than  fill  such 
an  institution.  It  is  understood  that  there  has  been  in  the  past  several 
hundred  thousand  dollars  available  for  tuberculosis  institutions.  If  this  is 
still  available  or  can  be  re-appropriated,  it  should  be  immediately  employed 
for  the  extension  of  sanatorium  accommodations  at  Warrensville. 

As  the  work  in  Cleveland  progresses,  and  indeed  before  very  long,  there 
will  also  develop  a  pressing  need  for  hospital  care  for  advanced  cases.  It  is 
suggested  that  at  least  200  beds  be  made  available  for  this  type  of  case,  prefer- 
ably in  connection  with  the  City  Hospital. 


372  Hospital  and  Health  Survey 

There  is  at  the  present  time  a  pressing  need  for  treatment  facilities  for 
open  active  cases  among  children.  A  ward  of  at  least  30  beds  should  be 
added  to  the  Warrensville  equipment  for  this  purpose. 

The  facilities  for  the  treatment  of  the  closed  cases  among  children  at 
Warrensville  are  inadequate  and  could  with  advantage  be  expanded  to  include 
20  additional  beds. 

Some  provision  should  also  be  made  for  surgical  cases  complicated  by 
tuberculosis,  at  City  Hospital  for  acute  and  at  Warrensville  Infirmary  for 
chronic  surgical  disabilities. 

Provision  should  also  be  made  for  complicated  tuberculosis  cases,  par- 
ticularly among  women,  where  the  disease  is  associated  with  pregnancy, 
syphilis,  or  other  conditions. 

There  is  at  the  present  time  an  urgent  demand  for  preventorium  insti- 
tutional facilities  for  children  under  five  years  of  age  who  have  incipient 
disease,  or  who  have  been  exposed  to  the  disease  and  are  in  an  under-par 
condition. 

There  is  probably  also  a  need  for  institutional  provision  for  the  type  of 
case  that  can  afford  to  pay  a  self-supporting  fee  for  hospital  treatment.  This 
would  add  approximately  450  beds  to  the  existing  equipment,  making  a 
total  of  968  beds. 

At  Warrensville  at  the  present  time  there  are  254  beds  for  adults  and  30  beds  for 
children,  or  a  total  of  284  beds.  If  to  this  should  be  added  200  beds  for  early  cases,  30 
beds  for  open  cases  among  children,  and  20  beds  for  closed  cases  among  children,  or  a 
total  of  250  beds,  the  grand  total  of  bed  facilities  at  Warrensville  would  amount  to  534 
beds.  If,  further,  200  additional  beds  were  provided  at  Warrensville  for  advanced  cases, 
as  has  been  planned  for  by  the  tuberculosis  leaders  in  Cleveland,  it  would  bring  the  capacity 
of  the  Warrensville  institution  to  734  beds.  This  would  make  a  decidedly  unwieldy 
institution  as  to  size,  and  from  that  point  of  view  it  would  be  more  advantageous  to  con- 
sider attaching  the  200  beds  for  active  advanced  pulmonary  adult  cases,  and  for  cases  held 
pending  distribution  to  sanatoria  outside  of  the  city,  to  a  city  institution,  such  as  the  City 
Hospital.  Provision  for  200  beds  for  pulmonary  tuberculosis  is  planned  in  the  proposed 
additions  to  the  City  Hospital. 

TUBERCULOSIS  EDUCATIONAL  PROGRAM 

An  educational  program  against  tuberculosis  may  develop  three  main  points  of  attack : 
against  infection,  against  active  disease  and  against  mortality.  Among  every  100  people 
in  the  average  community  there  are  80  or  90  infected  with  tuberculosis.  An  educational 
program  should  attempt  to  reduce  this  percentage.  In  these  same  100  people  at  any  one 
time  from  one  to  two  will  be  suffering  from  tuberculous  disease.  An  educational  program 
which  fails  to  prevent  infection  should  at  least  endeavor  to  prevent  tuberculous  disease. 
Approximately  10  of  the  average  group  of  100  people  are  going  eventually  to  die  of  tuber- 
culosis. An  educational  program  to  be  complete  must,  therefore,  aim  not  only  against 
infection  and  against  disease,  but  against  mortality. 

A  complete  educational  program  against  tuberculosis  may  find  its  development  in 
two  fields:    public  hygiene  and  personal  hygiene.     Public  hygiene  will  in  large  part  deal 


Tuberculosis  373 


with  the  equipment  for  hygienic  living.  Personal  hygiene  will  deal  with  the  modes  of 
existence.  Personal  hygiene  aimed  against  infection  will  be  of  the  suppressive  type, 
and  personal  hygiene  aimed  against  disease  will  be  creative  in  character.  Finally,  the 
chief  considerations  of  creative  personal  hygiene  are  three  in  number:  home  hygiene, 
food  hygiene  and  the  more  distinctively  personal  hygiene. 

There  follows  a  very  brief  skeleton  outline  of  some  of  the  main  considerations  in  the 
development  of  a  complete  educational  program.  For  the  utilization  of  this  program, 
not  only  will  the  details  have  to  be  filled  in,  but  the  suggestive  theoretical  considerations 
will  have  to  be  translated  and  developed  into  practical  illustrative  propaganda. 

The  custom  of  the  State  of  Missouri  might  with  great  benefit  be  followed  by  the 
State  of  Ohio,  through  state  legislation  or  by  the  Board  of  Education  of  Cleveland  through 
resolution  or  enactment  of  city  ordinance.  The  statutes  of  Missouri,  R.  S.  1909,  Section 
10,806,  provide  that  "special  instruction  as  to  tuberculosis,  its  nature,  cause  and  preven- 
tion, shall  constitute  a  part  of  the  course  of  instruction  and  be  taught  in  all  public  schools 
supported  wholly  or  in  part  by  public  money  or  under  state  control." 

EDUCATION  AGAINST  INFECTION 

Public  Hygiene. 

Milk  pasteurization. 

Elimination  of  common  utensils. 

The  enforcement  of  spitting  ordinances. 

The  encouragement  of  institutional  treatment,  with  enforced  segregation 
when  necessary,  particularly  for  the  protection  of  exposed  children. 

The  development  of  routine  medical  detection  machinery  for  all  types  of 
active  tuberculous  disease,  including  examination  work  in  schools,  fac- 
tories and  elsewhere. 

Personal  Hygiene  (Suppressive). 

The  avoidance  of  unnecessary  contact  with  the  sick. 

The  avoidance  of  common  utensils  or  other  points  of  intermediate  contact. 

The  avoidance  of  dangerous  coughers,  sneezers,  etc.,  and  the  encourage- 
ment of  respiratory  hygiene. 

EDUCATION  AGAINST  DISEASE 
Public  Hygiene  (Equipment  for  Living). 

The  encouragement  of  proper  housing  equipment,  with  education  against 
congestion  and  the  lack  of  facilities  for  cleanliness. 

Occupational  hygiene,  with  the  relation  of  overwork,  excessive  fatigue, 
unnecessary  dust,  and  other  industrial  hazards,  etc. 

The  development  of  special  medical  machinery  for  the  detection  of 
incipient  disease,  such  as  the  consultation  service. 


374  Hospital  and  Health  Survey 

Propaganda  to  emphasize  the  basic  importance  of  the  elimination  of 
extreme  poverty  and  destitution. 

The  promotion  of  special  hygienic  equipment  measures  and  practices,  such 
as  open-air  schools,  recreation  facilities,  posture  clinics,  nutrition  classes, 
etc. 

Personal  Hygiene  (Methods  of  Living — Creative). 

Home  Hygiene : 

Ventilation. 

Cleanliness,  hand  washing,  etc. 

Illumination,  etc. 

Food  Hygiene: 

Economy  and  selection. 
Home  care  and  preservation. 
Dietetic  control. 

Personal  Hygiene: 
Exercise. 
Rest. 

Recreation. 

Recognition  of  early  symptoms  as  danger  signals. 
A  moderate  life — avoidance  of  excess,  elimination  of  strain,  etc. 
Regular  medical  examinations. 
The  creation  of  a  "will  to  be  healthy." 

EDUCATION  AGAINST  MORTALITY 
Public  Hygiene. 

Popularization  of  hospital  and  sanatorium  treatment,  creation  of  public 
demand  for  adequate  clinical  and  nursing  service,  etc. 

Institutional  treatment  or  follow-up — economic  and  social  adjustment. 

Personal  Hygiene. 

Advice  to  seek  the  best  medical  opinion  early  and  follow  it. 

Information  regarding  the  danger  of  contagion  and  the  spread  of  the  disease. 

Education  against  drugs  and  patent  medicines. 

Emphasis  on  tuberculosis  therapy:    rest,  fresh  air,  food,  etc. 

Attractiveness  and  value  of  institutional  treatment,  with  minor  importance 

of  climatic  conditions. 
Education  regarding  the  proper  adjustment  of  the  arrested   case  to  life  and 

work. 


Tuberculosis  375 

ORGANIZATION 
The  Division  of  Health. 

The  Bureau  of  Tuberculosis. 

It  can  be  recommended  that  in  the  Division  of  Health  a  full-time  chief 
be  found  for  the  Bureau  of  Tuberculosis.  This  chief  should  administer  the 
activities  of  the  Bureau,  should  also  presumably  be  a  man  of  sufficient 
clinical  training  to  act  in  the  capacity  of  expert  tuberculosis  consultant,  and 
might  also  serve  in  a  third  capacity  as  head  of  the  tuberculosis  post-graduate 
instruction  work  at  the  Medical  School.  In  this  way  these  three  important 
services — administration,  consultation  and  instruction — might  be  effectively 
linked  together.  Such  a  service,  under  present  conditions  in  Cleveland,  if 
established  under  the  Division  of  Health,  would  probably  have  to  be  subsi- 
dized from  the  financial  resources  of  the  Anti-Tuberculosis  League. 

The  Statistical  Bureau. 

It  is  of  particular  importance  to  tuberculosis  study,  and  presumably  of 
great  importance  to  all  other  health  problems,  that  the  Bureau  of  Statistics 
be  further  developed  than  has  been  the  case  at  present.  At  the  present 
time  it  appears  that  not  enough  money  is  appropriated  for  this  work,  and 
that  the  records  are  inadequately  provided  for. 

From  a  statistical  point  of  view,  it  is  also  important  that  an  effort  be 
made,  in  figuring  tuberculosis  death  rates  in  the  future,  that  non-residents  be 
excluded  and  residents  dying  out  of  town  included.  The  records  for  the 
past  decade  at  least  should  be  gone  over  with  a  similar  object  in  view,  in 
order  to  furnish  a  statistical  basis  for  future  comparisons.  (See  special 
section  on  Statistics  in  Part  II.) 

The  Nursing  Staff. 

The  nursing  staff  could  with  advantage  be  materially  increased.  The  80 
nurses  for  the  Division  of  Health,  plus  approximately  32  nurses  of  the  Visiting 
Nurse  Association,  31  school  nurses  and  10  student  nurses  in  the  University 
District,  totaling  153  doing  generalized  public  health  nursing  work,  would 
have  to  be  supplemented  by  113  nurses  to  bring  the  total  to  what  is  con- 
sidered a  minimum  requirement,  making  available  one  public  health  nurse 
for  every  3,000  of  the  population,  or  266  nurses  for  Cleveland. 

While  the  generalized  system  seems  to  be  working  admirably,  there  are 
some  indications  of  the  need  of  greater  specialized  supervision  than  it  has 
been  possible  to  provide  to  date.  While  this  is  of  general  importance,  it  is  of 
particular  significance  in  tuberculosis  work,  if  a  special  interest  such  as 
tuberculosis  is  not  to  suffer. 

Case  Classification. 

There  has  been  recommended  a  somewhat  modified  system  of  current 
case  bookkeeping,  a  system  based  on  the  functional  tuberculosis  classification 
chart  developed  by  the  Frarningham  Community  Health  and  Tuberculosis 


376  Hospital  and  Health  Survey 


Demonstration.  This  chart  has  been  described  in  available  literature,  and 
need  not  be  discussed  in  detail  here.  The  system  of  classification  of  cases  is 
somewhat  modified,  on  the  basis  of  the  National  Tuberculosis  Association 
classification.  The  cases  are  then  tallied  on  a  current  functional  chart,  this 
chart  makes  clear  the  channels  through  which  new  cases  are  being  unearthed, 
shows  the  variety  of  early  cases  that  are  bound  to  be  discovered  in  any  com- 
munity, emphasizes  different  types  of  advanced  cases  and  distinguishes 
between  different  types  of  arrested  cases,  reflects  the  closeness  of  case  follow- 
up,  demonstrates  the  progression  or  retrogression  of  each  case  under  considera- 
tion, makes  simple  a  monthly  summing  up  of  case  records  by  a  health  center, 
encourages  the  persistent  follow-up  of  arrested  cases,  and  has  other  advan- 
tages too  detailed  to  be  discussed  here. 

Such  a  system,  if  incorporated  under  the  health  center  routine,  would 
greatly  facilitate  the  intimacy  of  contact  between  the  central  bureau  of 
tuberculosis  and  the  outlying  clinics,  an  object  to  be  accomplished  by  routine 
summaries  from  the  current  classification  chart,  submitted  regularly  to  the 
central  office. 

The  Anti-Tuberculosis  League, 

It  is  to  be  hoped  that  the  League  personnel  and  program  can  be  expanded  to  meet 
the  current  tuberculosis  situation  in  Cleveland.  The  League  requires  a  full-time  secre- 
tary, and  should  have  at  least  one  main  division  of  work,  an  educational  division,  with  an 
assistant  in  charge  of  that  division,  organized  for  educational  purposes.  This  division 
should  continue  the  follow-up  work  from  the  sanatorium,  the  occupational  therapy,  etc. 
and  should  be  primarily  concerned  with  the  development  of  the  comprehensive  program 
of  anti-tuberculosis  and  health  education  previously  outlined. 

If  for  reasons  of  local  expediency  it  turns  out  to  be  impracticable  to  develop  the  con- 
sultation service  and  other  newly  proposed  medical  services  in  the  Bureau  of  Tuberculosis 
of  the  Division  of  Health,  it  may  become  necessary  for  such  a  bureau  to  be  developed  in 
the  League  itself.  This  would  constitute  a  second  division  of  the  League;  namely,  a 
medical  division,  headed  by  a  medical  secretary,  to  help  in  the  development  of  the 
post-graduate  training  course  at  the  Medical  School,  to  foster  the  development  of 
institutional  facilities,  to  cooperate  with  the  Division  of  Health  dispensaries  in  the 
development  of  a  consultation  service,  and  possibly  to  operate  a  traveling  clinic  in 
the  county  outside  Cleveland.  Such  a  bureau,  even  if  developed  under  the  auspices 
of  the  League,  would  form  a  unit  in  organization  and  operation,  and  might  eventu- 
ally as  a  unit  be  transferred  to  the  official  health  body.  This,  however,  is  suggested 
simply  as  a  possible  alternative,  recognizing  that  all  of  this  work  logically  belongs  in  the 
Division  of  Health,  and  should,  if  possible,  be  developed  there  from  the  beginning. 

To  carry  out  such  a  program  the  League  would  require  a  secretary,  an  educational 
director  and  a  medical  director.  To  develop  an  educational  and  medical  program  without 
a  suggested  traveling  clinic  equipment  and  operation,  would  require  an  annual  budget  of 
approximately  $20,000.00.  With  such  a  traveling  clinic  the  estimated  annual  budget 
would  more  nearly  approximate  $35,000.00,  including  clinic  equipment.  It  is  understood 
that  the  League  could  probably  raise  this  amount  of  money  with  the  help  of  the  Welfare 
Federation,  supplemented  by  the  Red  Cross  Seal  Sale.  If,  however,  the  medical  work 
can  be  developed  under  the  Division  of  Health,  the  budget  required  would  be  approxi- 
mately fifteen  thousand  dollars. 


Tuberculosis  377 

The  Spirit  of  Cleveland 

CLEVELAND  has  always  been  a  pioneer  community,  a  community  with 
courage,  resourcefulness  and  vision.    A  forward-looking  city,  guided  by 
the  spirit  of  cooperation  and  good  will,  it  is  seeking  a  true  appraisal 
of  its  genuine  needs. 

In  the  past  the  city  has  admirably  accepted  the  challenge  to  make  Cleve- 
land the  national  leader  in  health  and  tuberculosis  work.  Its  obligations 
have  been  met  in  the  Cleveland  way. 

Having  accomplished  much,  it  was  legitimate  to  ask:  "What  is  the  next 
step  in  the  control  of  tuberculosis  in  Cleveland?" 

The  willingness  of  Cleveland  to  face  its  problems  with  patience  and 
courage,  its  social  motive,  its  spirit  of  digested  idealism,  all  give  assurance  of 
exceptional  accomplishment  in  the  future. 

It  remains  for  a  leading  American  municipality  to  demonstrate  that 
tuberculosis  can,  under  intense  urban  conditions,  be  controlled.  Cleveland 
possesses  the  knowledge,  the  resources  and  the  spacious-minded  leadership 
essential  to  this  task. 


378  Hospital  and  Health  Survey 


TABLE  I. 

Tuberculosis  Deaths  by  Age,  Pulmonary  and  Non-Pulmonary, 
1913-1918,  Inclusive 

Forms        Under  1  yr.   1-4      5-9     10-19    20-29   30-39   40-49    50-59    60-69      70       Total 

Pulmonary 45'      65       45       395     1465     1299       891       515       249       85       5054 

Non-pulmonary....  116     196       78       106         40       121         61         41         23       12         794 


Totals 161     261     123       501     1505     1420       952  556  272       97       5848 

Per  cent  of  total....  2.8      4.5      2.1        8.6      25.7      24.3        16.3  9.6  4.6        1.5      100. 

TABLE  II. 

Tuberculosis  Death  Rates  per  100,009  for  the  Years  1913-16,  Based  on  the 
Estimated  Population  by  Age 

Forms        Under  1  yr.   1-4      5-9     10-19    20-29   30-39   40-49  50-59  60-69      70      Total 

Pulmonary 45.6    12.7    10.3     54.5       148       172       178  188  189.4     144     116 

Other  Tuberculosis  113       50       20.2     14.4       13.7      15.2      10.3  16.7  19.4       26.4     20.3 

TABLE  III. 
Tuberculosis  Deaths  by  Sex  (All  Forms)  1914-1918,  Inclusive 

Sex                                                1914           1915            1916  1917  1918         Total 

Male _ 542             546               635  776  768           3267 

Female.._ _ 301             315               387  432  422           1857 


Totals 843              861              1022              1208  1190            5124 

TABLE  IV. 
Pulmonary  Tuberculosis  Deaths  by  Occupation,  1914-1918 

Occupation  Total  Deaths 

Housework 1107 

Laborer 985 

Clerk  (office) 185 

Student 181 

Machinist 165 

Teamster  and  Truckman 99 

Carpenter  and  Woodworker... _ 94 

Seamstress  and  Tailor 91 

Moulder , 62 

Clerk  (store) 56 

Metal  Worker 54 

Painter 49 

Salesmen  (traveling) r 46 

Saloon  Keeper 38 

Seaman 36 

Printer  and  Lithographer 35 

Cook 33 

Stenographer 33 


Tuberculosis 


379 


TABLE  V. 
Forms  of  Tuberculosis 

Percentage  of 
Total  Pulmonary  Non-Pulmonary  Non-Pulmonary 

Period  Tuberculosis  Deaths  Tuberculosis  Deaths  Tuberculosis  Deaths 

1917 1024  184  17.9 

1918 _ 1020  169  16.6 

1913-1918 5848  794  13.6 


TABLE  VI. 
Attendance  at  Health  Centers  for  1914-1918,  Inclusive 

Centers                                      1914             1915             1916             1917             1918  Total 

l._ 1,812      .     1,438           1,539           2,232           1,624  8,645 

2 2,630           3,008           3,074           2,232           1,788  12,732 

3 2,296           4,402           2,101           1,066               861  10,726 

4 1,645           2,087           1,755           1,201           1,201  7,889 

5 1,768           2,098           1,706           1,433           1,506  8,511 

6.__ 211            1,572           2,175           1,536           1,539  7,033 

7._ 148           1,906           1,646           2,246  5,946 

Totals 10,362         14,753         14,256  11,346  10,765  61,482 


TABLE  VII. 
Number  of  New  Cases  at  Health  Centers  for  1914-1918,  Inclusive 

New  Cases                                       1914           1915           1916  1917  1918  Total 

1 626             398             453  409  390  2,276 

2 546             663             554  468  443  2,674 

3 573             859         v  423  227  195  2,277 

4.__ 1 383             482             405  277  321  1,868 

5 464             533             428  393  363  2,181 

6 59             456             444  348  377  1,684 

7 25             352  332  393  1,102 

Totals 2,651         3,416         3,059  2,454  2,482  14,062 


380 


Hospital  and  Health  Survey 


TABLE  VIII. 

Illness  in  Special  Milk  Consumption  Study  Families  Among 
Adults  and  Children 


Adults  Children 

Causes  No.               Per  Cent  No.             Per  Cent 

General — 

Tuberculosis 88  3.95  24  .78 

Typhoid 1  .045  0  .0 

•  Whooping  Cough..._ 0  .0  9  •   .292 

Cancer _ 6  .27  0  .0 

Rheumatism. 12  .54  1  .032 

Contagious - 20  .90  73  2.37 

Other 0  .0  1  .032 

Nervous  and  Special  Senses — 

Spinal  Cord 12  .54  1  .032 

Cerebral  Hemorrhage 5  .225  0  .0 

Mental  Alienation..... 5  .225  0  .0 

Epilepsy - 0  .0  1  .032 

Other  Nervous 4  .18  1  .032 

Eyes  and  Ears.. 0  .0  14  .455 

Circulatory — 

Heart. 7  .315  4  .13 

Other._ 4  .18  0  .0 

Respiratory — 

Nasal  Fossa 0  .0  1  .032 

Bronchitis 6  .27  8  .26 

Pneumonia 4  .18  11  .358 

Asthma. 3  .135  0  .0 

Other. _ 7  .315  17  .552 

Digestive — 

Pharynx..._ 5  .225  7  .228 

Stomach  (ulcer,  etc.) 7  .315  7  .228 

Hernia 0  .0  2  .065 

Malnutrition 0  .0  22  .715 

Other...  _ 0  .0  9  .292 

Genito-urinary  (non-venereal) — 

Nephritis... 3  .135  0  .0 

Other 7  .315  0  .0 

Puerperal 

Normal  Child-birth 66  2.96  0  .0 

Skin .-  6  .27  6  .195 

Bones 1  045  1  .032 

External 13  .584  6  .195 

111  Denned— Miscellaneous.... 68  3.05  86  2.79 

Total -  360                  16.16  312  10.14 

Grand  Total >- 672—12.7% 


Tuberculosis 


381 


TABLE  IX. 

Tuberculosis — Active,    Suspicious,    and   Exposed,  in    Milk  Consumption    Study 

Families 

Adults                         Children  Total 

Forms                                       No.         Per  Cent        No.  Per  Cent         No.         Per  Cent 

Active 88             3.95             24  .78  112             2.11 

Suspicious 22                .99             20  .64  42                .79 

Exposed _ 7                .31             26  .84  33                .62 

Total 117              5.25             70  2.26  187             3.52 


TABLE  X. 

Methods  of  Milk  Purchasing 

How  Delivered  Number  of  Families 

0 4 

Bottled 779 

Bulk-_ 6 

Canned 67 

Bottle  and  Bulk _ 14 

Bottle  and  canned _ 212 

Bottle,  canned  and  otherwise 1 

Bottle  and  otherwise 2 

Bulk  and  canned _ 6 

Bottle,  bulk  and  otherwise 4 


Percentage  of  Families 

.4 

77.9 

.6 

6.7 

1.4 

21.2 

.11 

.2 

.6 

.4 


TABLE  XI. 

Amount  of  Milk  Consumed 

Daily  Amount  per  Amount  in  Bottle 

Family  or  Bulk 

No.  of  Families                                                                      Qts.  Qts. 

6 _ 0  0 

4- H  1 

65._ y2  32  y2 

358 _ 1  358 

86 : 1  yz  129 

274._ 2  548 

22 : iy2  55 

71 3  213 

5 - zy*  im 

19 4        ,  76 

10 5  50 


920 


1480 


382 


Hospital  and  Health  Survey 


TABLE  XII. 
Milk  Consumption  by  Relief  Families 

(Bottle  or  Bulk,  Only) 


Totals 


No.  of  Families 

Quarts  per  Day 

2 

0 

4 

M 

23 

K 

'  136 

l 

35 

iy2 

131 

2 

9 

2^ 

35 

3 

1 

3K 

10 

4 

4 

5 

i 390 

Total  Quarts 

0 

1 

11.5 

136 

52.5 
262 

22.5 
105 

3.5 
40 
20 


654 


TABLE  XIII 
Milk  Consumed  by  Non-Relief  Families 

(Bottle  or  Bulk,  Only) 


Totals 


No.  of  Families 

Quarts  per 

Day 

Total  Quarts 

1 

0 

0 

3 

H 

.75 

42 

y2 

21 

217 

i 

217 

51 

iy2 

76.5 

143 

2 

286 

13 

2H 

32.5 

36 

3 

108 

9 

sy2 

31.5 

9 

•    4 

36 

6 

5 

30 

> 530 

839.25 

THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

X.     Hospitals  and  Dispensaries. 

XI.     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 


The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plusthe  postage, from 


THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Premier  Press 

Cleveland,  O 


Venereal  Di 


enereai  disease 


Part  Five 


Cleveland    Hospital     and 
Health    Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Publisbed  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -  Ohio 


Preface 

The  Hospital  and  Health  Survey  off  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators: 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director  -of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the^Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

Page 

I.    General  Statement 

Present  Facilities .-■. 395 

Past  Accomplishments - 395 

Present  Needs..... 395 

Recommendations - 396 

II.   Medical  Phases 

Introduction — Prevalence — Size  of  Problem....  398 

Diagnosis -, 400 

Treatment 401 

Dispensaries  and  City  Hospital 404 

Division  of  Health -  410 

III.  Legal  Aspects 

Introduction — Relation  of  Law  Enforcement 

to  the  Medical  Problem 419 

Existing  Laws 421 

Amendments  Suggested 421 

Administration : 

Women's  Police  Bureau 424 

Citizens'  Committee 426 

Women's  Court 427 

Finger-Print  System 427 

Vice  Conditions - - 427 

IV.  Protective  Social  Measures 

Recreation ----- 429 

Preventive  W'ork  for  Women  and  Girls 

Women  Police 429 

Probation 429 

Institutional  Care  of  Sex  Delinquents 430 

V.   Sex  Education 

Sex  Education  for  Children. - 431 

Sex  Instruction  for  Young  Men  and  Women 

432 

Social  Hygiene  Information  for  Parents  and 

Leaders  of  Public  Opinion 432 

Ways  and  Means  of  Promoting  Educational 

Measures - 432 


Venereal  Disease* 

By 

Alec  N.  Thomson,  M.D. 
Mr.  Bascomb  Johnson 
Mrs.  Martha  P.  Falconer 
Mr.  F.  0.  Nichols 

I.    General  Statement 

PRESENT  facilities  in  Cleveland  for  the  control  of  the  venereal  diseases 
are,  generally  speaking,  as  satisfactory  as  those  in  the  more  advanced 
cities  throughout  the  United  States.  There  are  three  dispensaries 
treating  cases  of  gonorrhea  and  syphilis,  and  one  clinic  serving  as  a  diagnostic 
and  advisory  center.  Facilities  for  treating  cases  that  require  hospital  care 
exist  only  at  the  City  Hospital.  The  present  laws  for  the  prevention  of 
infection  through  sexual  promiscuity  are  in  the  main  adequate.  The  official 
machinery  for  the  enforcement  of  these  laws  exists,  but  in  certain  instances 
is  practically  inoperative.  The  institutions  that  are  a  necessary  corollary 
to  the  proper  functioning  of  this  machinery  are  in  part  lacking,  and,  where 
existent,  need  rearrangement  or  reorganization  to  fulfill  their  greatest 
usefulness. 

Other  facilities  that  are  distinctly  of  value  as  preventive  measures  (such 
as  recreation,  amusements,  playgrounds  and  the  like)  have  not  been  thor- 
oughly appreciated  as  factors  tending  to  reduce  or  control  the  venereal 
diseases,  nor  have  they  been  correlated  with  the  latter.  Facilities  for  the 
social  hygiene  education  of  the  general  public,  of  special  groups  (such  as 
teachers,  parents,  nurses,  doctors,  etc.)  and  of  community  leaders  may  be 
said  to  be  non-existent. 

Past  accomplishments  of  the  City  of  Cleveland  in  the  combating  and 
control  of  the  venereal  diseases  may  be  summed  up  by  saying  that,  aside 
from  such  treatment  facilities  as  have  been  available  through  the  dispen- 
saries, the  City  Hospital  and  the  general  medical  profession,  no  appreciable 
amount  of  continuous,  constructive  work  has  been  done.  In  this  respect 
Cleveland  does  not  differ  from  many  other  cities  of  the  same  size;  but,  with 
its  remarkable  community  spirit,  one  is  surprised  to  find  that  it  has  not 
forged  ahead  in  this  field  during  the  past  few  years.  The  Division  of 
Health  has  made  some  sporadic  attempts  under  great  handicaps  to  educate 
the  public,  and  the  clinics  have  grown  steadily,  but  no  concerted  effort  can 
be  said  to  have  developed. 

The  present  needs  of  Cleveland  are  the  present  needs  of  the  country  at 
large — a  greater  appreciation  by,  the  leaders  of  the  community  of  the  serious- 
ness and  prevalence  of  the  venereal  diseases,  as  well  as  a  greater  under- 
standing on  the  part  of  the  general  public  of  the  practical  and  comprehensive 
program  of  social  and  medical  measures  that  must  be  carried  out.     Perhaps 

•The  services  of  the  investigators  were  contributed  by  the  American  Social  Hygiene  Association 


396  Hospital  axd  Health  Survey 


the  compelling  need  of  the  moment  is  a  complete  community  understanding 
of  the  importance  of  promptly  availing  itself  of  competent,  adequate  treat- 
ment for  the  infected,  and,  as  a  corollary  to  this,  of  the  necessity  of  provid- 
ing adequate  treatment  facilities.  It  is,  of  course,  self-evident  that  the 
utilization  of  all  measures  which  may  be  brought  to  bear  against  the  further 
spread  of  gonorrhea  and  syphilis  must  be  promoted  simultaneously  if  any 
great  reduction  in  the  number  of  cases  is  to  be  secured.  Equally  urgent, 
then,  is  the  present  need  for  planning  a  general  educational  campaign  through 
every  available  channel  to  reach  the  many  groups  that  make  up  the  com- 
munity.   » 


RECOMMEND  A  TIONS 

The  methods  of  demonstrated  value  in  combating  and  controlling  the 
venereal f diseases  which  should  be  considered  in  determining  a  plan  for  a 
city  such^as  Cleveland  may  be  divided  into: 

/.   Protecting  Individuals  from  Exposure. 

(a)  An  educational  program  for  the  purpose  of  character  building,  through 
the  home,  schools,  churches,  associations  and  business  and  fraternal 
organizations. 

(b)  Instruction  of  the  public  regarding  public  health  and  hygiene  and  the 
need  for  adaptation  of  the  natural  but  controllable  instinct  of  sex  to  the 
environmental  conditions  resulting  from  our  present  manner  of  com- 
munal living. 

(c)  Enlightenment  of  the  general  public  upon  the  prevalence,  method  of 
spread,  economic  and  social  loss,  serious  consequences  to  the  individual 
and  damaging  effects  upon  posterity,  of  the  venereal  diseases.  This 
should  be  accomplished  through  the  appropriate  use  of  all  the  civic 
agencies  for  education  and  promotion  of  social  relations;  and  is  the 
peculiar  obligation  of  the  medical  profession,  through  the  medium  of 
its  membership,  supporting  the  efforts  of  the  Division  of  Health  and 
the  Academy  of  Medicine. 

(d)  Improvement  and  regulation  of  amusement,  entertainment  and  recrea- 
tion facilities  through  playgrounds,  clubs,  theaters  and  literary,  musical 
and  athletic  organizations,  by  appealing  to  and  developing  individual 
tastes  and  activities,  in  addition  to  stimulating  group  activities. 

(e)  Safeguarding  and  bettering  home  surroundings  and  influences  by  meas- 
ures tending  to  increase  home  comforts  and  attractions  and  better  hous- 
ing and  living  conditions.  Particular  stress  should  be  placed  upon  the 
encouragement  of  early  marriage  and  upon  such  social  measures  as  may 
be  developed  to  protect  and  aid  children  and  parents  in  securing  the 
normal  satisfactions  of  family  life.  The  proper  care  of  the  feeble-minded 
and  the  discouraging  of  unwise  mating  of  individuals  bear  upon  the 
lessening  of  the  number  of  exposures  to  infection. 

(f)  Warnings  to  individuals  regarding  specific  sources  of  infection;  and  per- 
sonal instruction  to  applicants  for  information  concerning  the  use  of 


Yenereal      Disease  397 

mechanical  and  antiseptic  methods  of  preventing  infection  either  extra- 
genital or  genital.  Measures  properly  included  under  this  heading  are 
discussed  in  Section  II  below,  devoted  to  medical  phases. 

2.  Elimination  of  Environmental  Conditions  Favoring  Dissemination  of 

Venereal  Diseases. 

(a)  Elimination  of  the  commercialized  aspects  of  prostitution. 

1.  Its  advertisement — The  best  advertisement  of  prostitution  is  the  red 
light  district  or  tolerated  house  open  to  the  public. 

2.  Its  protection — Such  districts  or  tolerated  houses  operate  in  violation  of 
law  and  cannot  exist  without  official  protection,  which  means  corrupt 
officials. 

3.  Its  exploitation — The  exploiter  is  the  go-between  or  middleman  whose 
interest  it  is  to  stimulate  both  the  supply  of  and  demand  for  prostitution. 
Under  this  head  come  the  illicit  activities  of  procurers,  panderers,  chauf- 
feurs, bell  boys,  keepers  of  hotels,  rooming  houses  and  apartments,  man- 
agers of  dance  halls,  cabarets  and  other  forms  of  commercialized  amuse- 
ments, who  cater  to  prostitution. 

(b)  Repression  of  the  individual  activities  of  men  to  purchase  sexual  grati- 
fication and  of  women  to  sell  themselves  for  this  purpose. 

1.  Prevention  of  solicitation  for  prostitution  or  sexual  gratification  by  either 
sex  in  public  places. 

2.  Repression  of  clandestine  prostitution  in  hotels,  rooming  houses  and 
apartments  by  passage  and  enforcement  of  prohibitory  laws  effective 
equally  against  both  sexes. 

3.  Provision  and  Maintenance  of  Facilities  for  Diagnosis,  Treatment  and 

Control  of  Infected  Persons. 

(a)  The  discovery  of  infected  individuals  through  laboratory  aids  to  diag- 
nosis, through  the  maintenance  of  an  advisory  clinic,  through  the  stimu- 
lation of  better  diagnostic  service  by  dispensaries  and  hospitals,  as  well 
as  through  examinations  made  by  the  general  medical  profession  in 
private,  public  and  industrial  practice. 

(b)  Provision  of  treatment  through  the  maintenance  of  dispensaries  with 
adequate  equipment  and  personnel  to  supplement  the  service  afforded 
by  the  medical  profession  and  the  enactment  of  legislation  against  treat- 
ment by  unqualified  persons. 

(c)  Control  of  infected  persons  through  thorough  instruction  regarding  the 
venereal  diseases  by  the  physician  responsible  for  the  treatment  of  such 
patients,  through  the  provision  of  hospital  facilities,  the  quarantine  of 
cases  under  certain  circumstances,  the  establishment  of  standards  for 
discharge  from  treatment  and  the  enforcement  of  penalties  for  exposing 
others  to  infection. 


398  Hospital  and  Health  Survey 

II.      Medical  Phases 

INTRODUCTION— PREVALENCE— SIZE  OF  PROBLEM 

THE  frequency  with  which  venereal  disease  occurs  in  civil  life  was  realized 
by  but  few  persons  until  the  United  States  entered  the  World  War. 
The  country  was  shocked  by  the  prevalence  of  gonorrhea  and  syphilis, 
as  shown  by  the  first  draft. 

Although  this  prevalence  is  recognized,  the  unorganized  defense  (until 
recently)  against  gonorrhea  and  syphilis  as  compared  with  other  communi- 
cable diseases  makes  it  impossible  to  obtain  material  upon  which  a  positive 
statistical  statement  may  be  based.  A  conservative  estimate,  however,  can 
be  made  to  approximate  conditions  existing  at  the  present  moment.  Upon 
these  estimates  certain  positive  and  constructive  plans  can  be  formulated. 

Cleveland  did  some  pioneer  work  in  venereal  disease  control,  and  has  in 
many  respects  made  much  progress.  It  is  reasonable  to  assume  that,  in 
general,  Cleveland  is  no  worse  nor  better  equipped  to  handle  the  problem 
than  any  other  American  city  of  its  size;  nor  is  the  total  amount  of  venereal 
disease  that  requires  attention  greater  in  Cleveland  than  elsewhere. 

How  much  venereal  disease  exists  in  Cleveland?  From  army  figures  we 
get  merely  an  idea  of  the  amount  of  venereal  disease  work  to  be  undertaken, 
for  it  must  be  realized  that  army  and  draft  board  figures  do  not  include 
boys  below  twenty-one,  men  over  thirty,  nor  the  women  and  children.  It 
must  be  further  understood  that  gonorrhea  and  syphilis  are  germ  diseases 
whose  mode  of  transmission  is  known;  that  they  are  found  in  all  walks  of 
life,  at  every  age  from  birth  to  old  age;  and,  finally,  that  they  are  respon- 
sible for  many  symptoms  and  conditions  classified  as  diseases  other  than 
those  generally  recognized  as  or  admitted  to  be  venereal  diseases. 

In  the  second  million  men  called  to  the  colors  in  the  late  war  275  cases 
of  venereal  disease  were  recorded  for  the  6,189  Cleveland  men  examined  at 
the  camps,  or  4.44%.  If  this  rate  of  4.44%  of  the  pick  of  Cleveland's  men 
were  found  infected,  it  is  reasonable  to  expect  to  find  at  lea&t  the  same  rate 
among  all  men  of  the  age  group  of  twenty-one  to  thirty  years  in  Cleveland 
now,  or  a  total  of  7,637. 

Venereal  diseases  have  been  reportable  but  a  very  short  time.  False 
modesty  still  lingers,  and  any  estimate  of  the  prevalence  of  gonorrhea  and 
syphilis  throughout  the  United  States  is  necessarily  incomplete.  In  a  very 
few  states  venereal  disease  has  been  reportable  for  more  than  a  year;  in 
only  one,  over  three  years.  The  figures  for  the  last  six  months  of  1919  are, 
therefore,  a  conservative  index  only  of  the  incidence,  and  justify  us  in  con- 
sidering them  as  a  marked  underestimation  of  prevalence.  The  number  of 
cases  of  gonorrhea  and  syphilis  credited  to  Ohio  during  the  last  six  months 
of  1919  in  the  U.  S.  Public  Health  Service  reports  was  7,380.  The  total  num- 
ber of  cases  reported  to  the  Ohio  State  Department  of  Health  for  the  period 
of  July-December,  1919,  was:  gonorrhea  4,438,  syphilis  3,869, making  a  total 


Venereal      Disease 


399 


of  8,307.  Of  this  number  there  were  reported  from  Cleveland  during  the 
same  period:  gonorrhea  246,  and  syphilis  497,  making  a  total  of  743  cases. 
During  this  same  period  the  City  Health  Division  informed  the  Survey 
that  911  cases  of  venereal  disease  had  been  reported,  which  is  a  smaller 
number  than  were  cared  for  by  the  clinics  or  were  reported  to  the  Cleveland 
Hospital  and  Health  Survey  by  the  physicians  of  Cleveland. 

In  the  following  table  five  states  and  Continental  United  States  as  a 
whole  are  compared.  An  equally  active  anti-venereal  campaign,  similar  to 
the  Ohio  State  Health  Department  program,  was  conducted  by  each  state, 
except  that  Ohio  had  not  "pushed"  reporting  to  quite  the  same  degree. 

VENEREAL  DISEASE  REPORTED  LAST  SIX  MONTHS  OF  1919 

S.  8b  G. 

Rate  Rate        Total 

Population     Gonorrhea         per  Syphilis  per      Rate  per 

(Est.)         (Reported)     100,000  (Reported)  100,000    100,000 

Continental  U.  S 106,871,294         92,218              86.  68,963  64.5          150.5 

Illinois 6,400,473           9,109            142.  5,652  88.2          230.2 

Massachusetts 3,889,607          4,996            128.  2,348  60.2         188.2 

Michigan 3,173,089           5,496            173.  3,253  102.4         275.4 

Minnesota.. 2,378,128          2,586            109.  1,797  75.6         184.6 

Ohio. 5,335,543           4,003              75.1  3,377  63.3         138.4 


The  dispensaries  of  Cleveland  treated  more  than  1,453  patients  for 
venereal  disease  during  1919.  From  correspondence  with  physicians  in 
Cleveland,  and  from  personal  inquiries  of  physicians  and  nurses  in  hospitals 
and  dispensaries  and  of  those  engaged  in  health  work  outside  of  hospitals 
in  Cleveland,  it  appears  probable  that  between  8,000  and  10,000  patients  in 
Cleveland  are  treated  annually  for  venereal  infections.  There  is  good 
reason  to  believe  that  there  are  in  any  metropolitan  community  at  least  as 
many  venereal  disease  patients  that  are  not  under  professional  medical  care 
as  there  are  diagnosed  and  under  treatment,  and  there  is  some  good  evidence 
that  there  are  generally  twice  as  many  such  patients  untreated  and  prob- 
ably unrecognized  as  there  are  under  medical  supervision.  Recalling  the 
careful  estimates  of  such  competent  students  as  Dr.  Prince  A.  Morrow 
(namely,  3%  of  the  population  infected),  and  using  the  present  day  infor- 
mation as  a  further  basis  of  estimating,  we  may  properly  offer  as  a  reason- 
able guess  that  approximately  30,000  individuals  (3.8%  of  the  population) 
are  today  suffering  from  gonorrhea  or  syphilis  in  Cleveland.  This  repre- 
sents the  traffic  to  be  handled  in  office,  clinic  and  hospital.  Cleveland  must, 
therefore,  prepare  to  combat  the  wastage  due  to  gonorrhea  and  syphilis, 
diseases  that  are  preventable  by  known  and  proven  methods — medical, 
legal,  educational  and  environmental. 


400  Hospital  and  Health  Survey 

DIAGNOSIS 

The  facility  for  the  diagnosis  of  gonorrhea  and  syphilis  provided  through 
the  Health  Division  laboratory,  while  probably  not  sufficient  for  the  full 
volume  of  business  that  can  be  developed,  is  meeting  the  present  needs. 
This  is  adequate  at  the  moment  from  the  standpoint  of  technical  procedure: 
the  provision  of  materials,  such  as  slides,  Wassermann  tubes,  etc.  The 
Division  of  Health,  however,  seems  to  be  rendering  unsatisfactory  service 
from  the  standpoint  of  returning  reports,  as  there  is  considerable  complaint 
about  the  long  period  of  time  elapsing  between  the  sending  of  the  specimen 
to  the  Division  and  the  receipt  of  the  result  by  the  physician.  The  pres- 
ent scheme  of  utilizing  the  temporary  service  of  a  college  student  as  serolo- 
gist  on  a  part-time  basis  is  not  sound  from  the  standpoint  of  organization, 
nor  is  it  productive  of  a  feeling  of  confidence  on  the  part  of  the  general  medi- 
cal profession. 

During  the  first  ten  months  of  1919  the  laboratory  of  the  City  Health 
Division  made  525  microscopic  examinations  for  the  detection  of  gonorrhea. 
During  the  same  period  the  Wassermann  test  for  the  detection  of  syphilis 
was  performed  upon  5,807  specimens  of  blood.  The  increase  in  demand  for 
laboratory  aid  in  the  diagnosis  of  gonorrhea  and  syphilis  has  been  gradual, 
but  has  shown  a  steady  growth,  indicating  increasing  appreciation  of  the 
value  of  the  laboratory  as  a  factor  in  diagnostic  procedure. 

Private  laboratory  facilities  in  the  City  of  Cleveland  are  adequate.  A 
number-  of  physicians  maintain  their  own  laboratories.  Many  physicians 
connected  with  hospitals  use  the  laboratory  facility  of  the  institution  with 
which  they  are  connected.  Thus,  in  addition  to  the  work  done  by  the 
laboratory  of  the  Division  of  Health,  a  very  considerable  number  of  blood 
and  microscopic  tests  are  done  by  the  hospital  and  private  laboratories. 
The  Health  Division  laboratory  figures  can  be  taken  as  an  index  of  the 
volume  of  private  and  hospital  work  that  is  done  in  the  field  of  laboratory 
diagnosis. 

There  is  no  supervision  nor  regulation  of  private,  hospital  or  commercial 
laboratories  by  the  Health  Division.  Laboratories  used  for  the  detection 
and  control  of  communicable  diseases  must  be  adequately  equipped  and 
staffed  with  thoroughly  competent  personnel  in  order  to  be  of  real  value  to 
the  city. 

The  so-called  "Government  Diagnostic  Clinic,"  64  Public  Square,  Cleve- 
land, Ohio,  is  probably  responsible  for  a  considerable  percentage  of  the 
increase  in  the  work  done  by  the  laboratory  of  the  Health  Division.  From 
September  10  to  November  22,  1919,  this  clinic  made  a  total  of  265  exami- 
nations of  individuals  suspected  of  being  infected  with  either  gonorrhea 
or  syphilis.  About  216  cases  were  received  from  the  courts,  39  cases  were 
referred  by  doctors,  and  10  cases  came  of  their  own  volition  because  they 
had  heard  of  the  facility.  The  quarters  are  adequate  for  the  purposes 
of  a  diagnostic  clinic  and  are  well  maintained;  but  they  are  in  an  old,  unat- 
tractive building  and  are  inconvenient  of  access  from  the  street.     The  loca- 


Venereal      Disease  401 

tion  on  the  Public  Square  is  convenient  and,  with  proper  publicity,  most 
excellent  service  can  be  rendered  by  such  a  clinic  organized  purely  as  an  ad- 
visory and  diagnostic  station. 

RECOMMENDATIONS 

It  is  recommended  that  the  Cleveland  Academy  of  Medicine  emphasize  to  physicians 
the  importance  and  relative  value  of  laboratory  aid  in  diagnosis,  in  the  control  of  treat- 
ment and  as  a  check  before  the  discharge  of  patients  as  cured; 

That  the  Division  of  Health  establish  rules  and  regulations  for  standards  of  pro- 
cedure, equipment  and  inspection  of  laboratories  offering  facilities  that  have  any  rela- 
tion to  the  diagnosis  of  communicable  diseases.     (See  page  416.) 

That  the  Division  of  Health  serological  laboratory  be  placed  on  a  sound  basis  of 
organization  with  full  time  personnel; 

That  the  diagnostic  clinic  be  continued,  preferably  as  a  part  of  the  central  downtown 
dispensary.     (See  chapter  on  Dispensaries,  Part  X.) 

TREATMENT 

In  considering  the  treatment  of  venereal  diseases  we  recognize  the  need 
for  facilities  for  the  very  poor,  the  self-supporting  group  that,  cannot  finance 
the  additional  cost  of  long  continued  medical  care,  as  well  as  the  group  that 
can  pay  the  entire  cost  of  treatment.  Cleveland,  like  all  progressive  com- 
munities, has  developed  dispensaries  to  cover  the  need  of  those  unable  to 
pay,  and  was  the  third  city  to  establish  pay  clinics  for  treating  venereal 
diseases  in  the  group  that  is  normally  self-supporting  but  unable  to  meet 
the  financial  stress  of  specialized  treatment  over  a  considerable  period  of 
time.  The  third  evening-pay-clinic  established  in  the  United  States  is  at 
Mt.  Sinai  Hospital,  which  is  doing  an  admirable  piece  of  work.  One  of  the 
largest  and  best  syphilis  clinics  in  the  country,  conducted  under  the  most 
unfavorable  conditions  as  far  as  quarters  are  concerned,  is  at  Lakeside 
Hospital.  Charity  Hospital  established  a  clinic  for  venereal  diseases  in 
September,  1919. 

In  general,  the  dispensary  facilities  for  treating  gonorrhea  and  syphilis 
are  inadequate,  although  the  personnel  is  generally  competent,  interested 
and  anxious  to  improve.  The  patients  get  good  treatment,  under  condi- 
tions (except  at  Mt.  Sinai)  that  not  only  make  the  work  of  the  doctors 
difficult  but  also  must  have  a  very  depressing  effect  upon  the  patient.  It  is 
not  possible  to  gauge  the  clinics  accurately,  because  of  the  inadequacy  of 
the  record  systems.  No  definite  attempt  has  been  made  by  the  clinics  to 
measure  their  own  efficiency,  to  determine  costs,  or  to  plan  for  future^ad- 
vancement. 

Hospital  beds  are  required  in  but  few  cases  of  venereal  diseases.  When 
required,  the  need  for  beds  for  such  patients  is  urgent,  frequently  as  a  matter 
of  public  health  protection. 


402  Hospital  and  Health  Survey 

Hospital  facilities  for  treatment  of  the  venereal  diseases  may  be  said  to 
be  practically  non-existent,  as  Cleveland  still  maintains  the  age-old  attitude 
that  gonorrhea  and  syphilis  must  not  be  admitted  to  a  hospital.  This  seri- 
ously handicaps  the  work  of  the  private  physician  as  well  as  the  work  and 
development  of  the  out-patient  department  of  the  institution. 

The  only  available  hospital  facilities  are  at  the  City  Hospital,  with  the 
exception  of  almost  negligible  provision  of  beds  for  women  at  Lakeside  in 
connection  with  the  gonorrhea  clinic.  The  number  of  beds  provided  at 
City  Hospital  is  not  sufficient  for  more  than  the  care  of  those  cases  that 
require  control  by  quarantine  because  of  the  patients'  lack  of  ability  or 
actual  unwillingness  to  cooperate  in  the  protection  of  the  public  health. 
There  are  available  for  this  purpose  75  beds  for  syphilis  and  50  beds  for 
gonorrhea. 

It  is  practically  impossible  for  a  venereally  infected  person,  who  is  will- 
ing and  able  to  pay,  to  be  admitted  to  any  hospital  in  Cleveland  for  gonor- 
rhea or  syphilis  in  the  communicable  stages.  It  is  the  general  consensus  of 
medical  opinion  throughout  the  country  that  patients  infected  with  syphilis 
or  gonorrhea  present  no  problem  in  hospital  administration  and  medical 
and  nursing  services  of  greater  menace  to  the  other  patients  or  attendants 
in  the  hospital  than  do  those  suffering  from  such  diseases  as  typhoid,  pneu- 
monia, infected  wounds,  and  the  like.  The  latter  group  of  communicable 
diseases  are  regularly  admitted  to  the  general  hospitals  without  question. 
The  hospital  door  closed  against  gonorrhea  and  syphilis  is  a  relic  of  the  doc- 
trine that  venereal  disease  is  the  just  punishment  for  a  moral  transgression, 
and  is  not  based  upon  any  inherent  technical  difficulty  of  hospital  man- 
agement. 

It  is  probable  that  many  cases  of  venereal  disease  are  admitted  to  the 
hospitals  of  Cleveland  under  a  ""camouflage"  diagnosis.  Cases  have  been 
brought  to  the  notice  of  the  Cleveland  Hospital  and  Health  Survey  in  which 
the  individual,  because  of  his  environment,  such  as  living  in  a  hotel  or  board- 
ing house,  was  unable  to  follow  the  advice  of  his  physician,  and  in  some 
instances  was  actually  put  out  of  his  place  of  abode.  It  is  impossible  to 
care  properly  for  these  cases  under  existing  conditions.  They  are  not  en- 
titled to  admission  to  the  City  Hospital  because  they  are  capable  of  paying 
for  their  care;  and,  in  spite  of  this  fact,  there  is  no  place  where  they  can  be 
provided  with  the  care  for  which  they  can  pay. 

Treatment  for  gonorrhea  and  syphilis  by  private  physicians  in  the  city 
of  Cleveland  is  available  through  a  group  of  specialists,  and  of  course  is  car- 
ried on  by  a  large  number  of  physicians  who  are  not  specializing  in  venereal 
diseases.  As  a  result  of  the  questionnaire  sent  to  the  physicians  of  the 
city,  we  find  the  number  of  venereal  disease  cases  treated  by  private  physi- 
cians to  be  difficult  of  estimation.  2,060  cases  were  reported  by  the  241 
physicians  that  replied  to  the  Survey's  questionnaire.  A  very  considerable 
percentage  of  patients  was  reported  as  having  discontinued  treatment  before 
having  been   cured.     The  reasons  given  were  the  usual  reasons  that  are 


Venereal      Disease  403 


heard  everywhere:  "continued  treatment  at  free  clinics,"  "lack  of  funds," 
"unwillingness  to  pay  fee,"  "carelessness,"  "dislike  of  treatment,"  "removal 
from  city,"  and  similar  excuses. 

Without  doubt  the  medical  profession  of  Cleveland  as  a  whole  ranks  as 
high  as  in  any  city  with  an  equal  number  of  physicians.  The  treatment  of 
the  disease  is  oftentimes  scientifically  outlined,  but  the  patient's  individual 
problem  is  frequently  neglected — his  or  her  economic  status,  environment, 
personal  feelings,  and  the  like,  are  given  scant,  if  any,  consideration.  It 
must  be  realized  that  the  average  doctor  has  neglected  the  social  phase  of 
medical  work,  both  as  general  practitioner  and  as  specialist,  in  that  he  has 
made  no  attempt  to  follow  up  the  patient  who  discontinues  treatment. 

RECOMMEND  A  TIONS 

It  is  recommended  that  all  general  hospitals  change  the  rules  of  admission  so  that 
there  may  be  no  discrimination  against  venereal  diseases,  and  that  pay  beds  may  be  made 
available  for  gonorrhea  and  syphilis  in  any  stage  of  the  diseases. 

That  each  hospital  that  maintains  a  dispensary  for  the  treatment  of  venereal  diseases 
organize  a  special  department  for  the  purpose  of  correlating  the  dispensary  and  hospital 
work  in  the  care  of  these  diseases,  and  that  a  definite  bed  allotment  for  free,  part-pay  and 
pay  patients  be  assigned  to  the  reorganized  venereal  disease  service.  The  service  can  be 
classified  in  the  hospital  organization  singly,  in  one  unit,  as  the  Department  of  Venereal 
Disease;  or  into  three  divisions:  Urology,  Dermatology  and  Gynecology.  In  this  latter 
plan  syphilis  would  be  assigned  to  Dermatology,  gonorrhea  in  the  male  to  Urology,  and 
gonorrhea  in  the  female  to  Gynecology. 

That  closer  cooperative  arrangements  be  developed  between  the  clinics  and  the  City 
Hospital  for  the  care  of  indigent  and  irresponsible  cases  at  the  hospital,  with  more  effective 
methods  for  the  return  of  these  patients  to  the  clinic  for  after-care  following  their  release 
from  the  hospital. 

That  the  City  Hospital  administration  be  so  improved  and  supported  that  hospital 
or  city  politics  will  not  be  able  to  ruin  what  can  and  should  be  the  biggest  and  best  venereal 
disease  service  in  the  city. 

That  the  Academy  of  Medicine  bring  to  the  attention  of  all  physicians  of  Cleveland 
the  sociological  aspects  of  venereal  diseases,  and  place  squarely  before  the  doctor  his 
peculiarly  strategic  relation  to  the  problem.  This  might  well  be  done  by  letters,  pam- 
phlets, clinics,  meetings  and  the  use  of  such  clinical  motion  pictures  as  are  produced  by 
the  governmental  and  other  agencies  engaged  in  the  national  campaign  for  the  control  of 
gonorrhea  and  syphilis. 

That  private  physicians  be  urged  to  cooperate  in  the  educational  and  social  protec- 
tive work  which  tends  to  reduce  the  number  of  exposures. 

That  physicians  prepare  themselves  to  advise  exposed  individuals  as  to  means  for 
prevention  of  infection ;  and  equip  their  offices  and  dispensaries  with  facilities  for  prophy- 
lactic treatment,  supervise  such  treatment  when  it  will  be  of  value,  and  maintain  contact 
with  the  exposed  person  so  advised  and  treated  during  the  period  of  presumed  incubation. 


404  Hospital  and  Health  Survey 

That  the  Bureau  of  Venereal  Diseases  in  the  Division  of  Health  cooperate  actively 
with  the  Academy  of  Medicine  in  the  diagnosis,  treatment  and  control  of  venereal  dis- 
eases; and  to  this  end  receive  the  benefit  of  the  opinion  and  advice  of  a  special  committee 
of  the  Academy,  appointed  from  among  its  members,  in  matters  of  educational  policy  and 
administrative  control  of  patients. 

DISPENSARIES  AND  CITY  HOSPITAL 

Cleveland  has  three  dispensaries  that  maintain  clinics  for  the  treatment 
of  gonorrhea  in  the  adult  male  and  syphilis  in  both  sexes  and  all  ages.  Gonor- 
rhea in  the  female  and  in  children  is  cared  for,  if  cared  for  at  all,  in  the  de- 
partments of  Gynecology  and  Pediatrics.  No  clinic  is  located  in  quarters 
that  tend  to  promote  the  best  effort  of  the  doctors  or  the  most  cooperation 
on  the  part  of  the  patient.  One  clinic  (Mt.  Sinai)  has  quarters  in  a  remodeled 
residence  that  meet  the  requirements  of  cleanliness,  relative  privacy,  separate 
waiting  rooms  for  the  sexes,  and  confidential  conference  between  physician  or 
social  worker  and  patient. 

The  patients  are  drawn  to  each  of  the  venereal  disease  dispensaries  from 
all  parts  of  the  city,  and  there  is  a  great  deal  of  cross  traffic.  The  location 
of  the  clinics  is  brought  to  the  attention  of  the  general  public  by  means  of 
a  large  placard  posted  by  the  Division  of  Health  in  a  few  public  places, 
such  as  toilets,  shops,  and  the  like. 

In  general  it  can  be  said  that  good  professional  care  is  available  at  all  the 
clinics,  although,  under  the  difficulties  inherent  in  poor  and  crowded  quar- 
ters, by  no  means  the  best  that  the  physicians  are  capable  of  rendering. 

RECOMMEND  A  TIONS 

It  is  recommended  that  the  city  be  districted  and  the  public  toilets  located  in  each 
district  be  thoroughly  placarded  by  the  Division  of  Health  to  call  attention  to  the  venereal 
disease  clinics  in  the  district;  and  that  additional  publicity  be  given  all  the  clinics  in  places 
such  as  railroad  stations,  industrial  plants,  public  toilets,  and  the  like,  which,  because 
they  are  primarily  used  by  people  from  all  parts  of  the  city,  will  not  fall  readily  into  a  dis- 
trict plan. 

That  a  new,  smaller  and  more  attractive  placard  be  prepared  by  the  Division  of  Health 
for  this  purpose.  The  number  of  placards  required  will  exceed  10,000  if  complete  coopera- 
tion of  the  industrial  plants  is  secured. 

That  new  clinics  be  established  on  the  west  side  and  southwest  side  of  the  city. 

That  the  present  so-called  "Government  Clinic"  be  developed  into  a  diagnostic  and 
advisory  clinic,  maintained  or  closely  supervised  by  the  City  Division  of  Health,  properly 
advertised  throughout  the  entire  city;  that  it  refer  to  private  physicians  all  applicants 
that  can  pay,  and  refer  to  the  clinics  serving  the  district  in  which  the  patient  resides  all 
applicants  that  cannot  pay  the  private  practitioner's  fee ;  that  it  serve  as  a  center  to  which 
the  physician  may  send  his  patients  for  diagnostic  assistance;  and  that  it  be  incorporated 
as  part  of  the  proposed  central  downtown  dispensary.  (See  chapter  on  Dispensaries, 
Part  X.) 


Vex  ere  a  l      Disease 


40.5 


Chart  of  Cleveland  showing  distribution  of  patients  treated  at  Lakeside,  Charity 
and  Mount  Sinai  Hospital  Dispensaries  for  venereal  diseases,  according  to 
residence  by  Health  Division  Districts.  The  percentages  of  patients  recorded 
at  each  dispensary  as  living  in  a  given  district  are  shown  in  parallel  bars. 
The  total  cases  for  each  hospital,  upon  which  the  chart  was  based,  are  as 
follows: 

Lakeside 1,062  cases  of  syphilis 

Charity.. 140  cases  of  venereal  disease 

Mount  Sinai... 250  cases  (Syphilis,  65%;  Gonorrhea,  35%) 


The  narrow  eastern  end  of  District  6,  extending  along  the  lake  shore  is  not  included  in  this  map. 


406  ,  Hospital  and  Health  Survey 

That  supervision  of  the  clinics  and  the  establishment  of  reasonable  standard  mini- 
mum requirements  for  their  equipment  and  services  be  undertaken  by  the  Division  of 
Health  after  conference  with  the  proposed  Dispensary  Committee  of  the  Cleveland  Hos- 
pital Council;  and  that  no  dispensary  (public,  private  or  commercial)  be  permitted  to 
treat  gonorrhea  or  syphilis  unless  the  requirements  are  met  as  certified  by  the  Division  of 
Health.     (See  page  417.) 

That  more  educational  work  be  done  in  all  the  clinics  by  means  of  personal  interviews, 
pamphletSj  wall  placards  and  similar  methods. 

That  printed  material,  such  as  cards,  pamphlets,  wall  charts,  and  the  like,  be  pro- 
vided for  the  clinics  by  the  Division  of  Health. 


Lakeside 
Syphilis  Clinic — Day — Men,  Women  and  Children 

A  patient  who  applies  for  treatment  at  this  clinic  must  apply  at  the 
admission  desk  in  the  main  dispensary,  receive  the  medical  record,  walk 
across  Lakeside  Avenue  to  the  clinic  building,  wait  in  a  small  crowded  room 
for  the  opportunity  to  see  the  doctors,  then  visit  the  social  worker,  then 
return  to  the  main  building  to  turn  in  the  medical  record  and  have  any 
prescription  filled  or  receive  salvarsan,  before  being  free  to  go  home.  This 
useless  consumption  of  time,  and  exposure  to  inclement  weather,  coupled 
with  the  unsightly  old  wooden  tenement  that  has  never  been  remodeled  to 
meet  clinic  purposes,  is  an  affront  to  the  self-respect  of  the  patient  and  a  dis- 
couragement to  the  personnel.  During  the  winter  months  this  building  is 
improperly  heated  and  inadequately  supplied  with  water.  At  times  there 
is  no  water. 

Educational  work  with  the  patients  for  the  protection  of  the  individual, 
the  family,  and  the  general  public,  is  well  done.  The  personal  relationship 
between  the  staff  and  the  patient  is  excellent,  but  is  maintained  in  spite  of 
the  handicapping  conditions  mentioned  above. 

The  patients  are  educated  to  the  great  need  for  treatment  continued  over 
a  long  period  of  time;  and,  if  they  fail  to  keep  their  appointments,  are 
requested,  by  postal  card,  to  return.  This  failing,  effort  is  made,  by  home 
visits,  to  bring  the  patient  back  to  treatment.  Effort  is  also  made,  with 
considerable  success,  to  bring  to  the  clinic  the  other  members  of  the  patient's 
family. 

Largely  due  to  the  personality  of  the  physicians  and  the  social  worker, 
the  handicap  of  poor  quarters  is  overcome  and  the  clinic  "atmosphere"  is 
quite  human.  That  the  patients  are  aroused  to  an  interest  in  their  own 
welfare,  as  well  as  in  the  protection  of  the  public  health,  is  evidenced  by  the 
enrollment  of  800  cases  of  syphilis — largely  by  the  "family  groups" — under 
observation  and  treatment. 


Venereal      Disease  407 


Syphilis  Clinic — Evening — Pay 

The  general  personnel  is  the  same,  and  similar  measures  are  followed. 
As  this  clinic  is  housed  in  the  main  dispensary  building,  it  presents  a  dis- 
tinctly better  appearance  and  can  be  managed  more  efficiently. 

About  400  syphilis  cases  are  registered  as  under  observation  or  treat- 
ment. Compliance  by  the  dispensary  management  with  the  simple  recom- 
mendations of  the  personnel  would  greatly  increase  the  efficiency  of  the 
clinic  and  would  promote  the  comfort  and  convenience  of  the  patients. 

RECOMMENDA  TIONS 

It  is  recommended  that,  because  of  the  existing  handicaps  inherent  in  the  present 
quarters,  the  growth  of  this  clinic  be  checked;  unless  the  volume  of  work  be  taken  care 
of  by  the  increasing  usefulness  of  the  other  clinics  and  the  opening  of  new  clinics,  and  the 
overcrowding  be  overcome  by  the  separating  of  the  syphilis  cases  from  the  dermatological 
cases. 

Gonorrhea — Male 

The  clinic,  aside  from  the  actual  professional  treatment  of  the  "case," 
in  no  way  meets  the  requirements  of  a  modern  clinic  for  treating  communi- 
cable diseases.  The  quarters  are  cramped.  There  is  no  privacy.  No 
attempt  is  made  to  follow  up  the  patients  that  fail  to  continue  under  treat- 
ment until  no  longer  a  menace  to  the  community.  Little  or  no  effort  is  made 
to  educate  the  patient  regarding  his  condition  for  either  his  own  good  or  the 
protection  of  the  public  health. 

Gonorrhea — Female 

The  Gynecological  Department  treats  gonorrhea  in  women  and  vaginitis 
in  children,  but  has  only  32  women  and  about  20  children  registered.  Re- 
cently a  social  worker  was  detailed  to  the  clinic.  Hospital  beds  are  avail- 
able, and  the  method  for  treatment  calls  for  three  or  four  days'  hospitaliza- 
tion. This  is  the  only  clinic  in  Cleveland  for  women  suffering  from  gonor- 
rhea that  provides  any  bed  facilities  for  its  patients.  If  really  active  work 
were  done  in  conjunction  with  the  men's  clinic,  the  women's  clinic  should 
be  very  much  increased  in  its  facilities,  proportionate  to  the  accommoda- 
tions of  the  men's  clinic.  An  excellent  public  health  protection  should  be 
available  to  Cleveland  through  the  Lakeside  Dispensary  Gonorrheal  Clinics. 


RECOMMENDATIONS 

It  is  recommended  that  a  complete  reorganization  of  the  gonorrheal  service  of  the 
Lakeside  Dispensary  be  undertaken,  in  order  that  both  male  and  female  patients  may 
receive^adequate,  humane  treatment  under  conditions  that  will  tend  to  increase  rather 
thandestroy  the*self-respect  of  the  patients. 


408  Hospital  and  Health  Survey 

That  a  follow-up  systerr.  be  established. 

That  adequate  quarters  be  provided. 

That  the  evening  and  day-time  clinics  be  under  the  same  medical  supervision. 

That  a  responsible  person  be  placed  in  charge  of  the  men's  service,  and  that  this 
physician  be  the  urologist  to  the  hospital  and  to  the  dispensary. 

That  the  placards  advertising  the  "pay  clinics"  be  removed  from  the  dispensary,  on 
the  ground  that  they  are  justly  criticised  by  the  medical  profession  as  being  too  com- 
mercial, particularly  when  considered  in  conjunction  with  the  general  method  of  organ- 
ization of  the  evening  pay  clinics.  These  clinics  are  practically  distinct  from  the  dispen- 
sary day  clinic,  and  are  not  under  the  supervision  of  the  hospital  staff. 

Mt.  Sinai 

Gonorrhea — Men.     Syphilis — Men.  Women  and  Children 

Evening — Pat/ 

This  clinic,  located  in  a  remodeled  dwelling  (semi-detached),  is  well 
arranged  on  two  floors,  and  has  separate  waiting  rooms  for  men  and  women. 
It  is  well  equipped,  clean,  efficiently  and  humanely  managed.  Every  effort 
is  made  to  impress  the  patient  with  the  seriousness  of  his  condition  and  the 
importance  of  continuous  treatment  and  observation  until  he  is  pronounced 
cured  by  the  physician.  Follow-up  of  patients  that  do  not  return  for  treat- 
ment is  done  by  mail,  but  house  visiting  is  done  only  in  exceptional  cases. 

The  clinic  is  rapidly  outgrowing  its  present  quarters,  although  it  is  still 
possible  to  maintain  a  considerable  degree  of  privacy.  This  tendency  to 
crowding  can  be  met  by  an  increase  in  personnel  and  the  opening  of  the 
clinic  every  night  instead  of  only  three  times  a  week. 

RECOMMENDA  TIONS 

It  is  recommended  that  the  service  be  improved  by  the  addition  of  a  clinic  clerk  and 
the  use  of  a  social  worker,  so  that  follow-up  by  mail  may  be  re-established  and  consistently 
carried  out,  by  using  a  less  cumbersome  system  of  form  cards  for  this  purpose  and  allow- 
ing a  shorter  time  interval  to  pass  before  follow-up  work  is  begun. 

That  the  clinic  be  open  every  night  except  Sunday  in  order  that  it  may  meet  the 
demand  bound  to  result  from  the  national,  state  and  local  campaign  for  combating  venereal 
diseases. 

That  a  gonorrhea  clinic  for  women  be  established. 

St.  Vincent's  Charity  Hospital 

Gonorrhea — Evening — Male 

This  clinic  was  established  in  September,  1919,  and  has  grown"  very 
rapidly — so  rapidly,  in  fact,  that  organization  has  not  kept  pace  with  growth. 
Administration  is  not  smooth  and  there  is  no  separation  of  patients  in  the 
waiting  room  by  age,  sex.  or  color. 


Venereal      Disease  409 


Educational  work  with  patients  is  not  carried  out  to  any  great  degree, 
and  a  full  understanding  of-  the  function  of  a  modern  clinic  that  deals  with  a 
communicable  disease,  such  as  syphilis  or  gonorrhea,  is  apparently  lacking. 
There  seems  to  be  no  responsible  direction  of  the  clinic  by  the  physician  in 
charge.  The  staff  is  irregular  in  arriving  and  departing.  The  great  need  of 
a  clinic  in  this  area  is  demonstrated  by  the  growth  of  this  clinic  despite  the 
irregular  service  rendered. 

Facilities  exist  for  the  development  of  a  modern  clinic  that  would  render 
positive  service  to  the  patients  in  a  location  of  great  strategic  value  for  the 
protection  of  the  community.  With  more  time  for  organization,  with  careful 
study  of  the  problem  of  clinic  management,  with  better  social  treatment  of 
the  patient  by  the  personnel,  and  with  a  definite  follow-up  system  to  bring 
back  the  patients  that  discontinue  treatment,  this  clinic  can  fill  an  important 
need  of  the  city  of  Cleveland — a  responsibility  not  now  being  met. 

Gynecology — Female 

Gonorrhea  in  women  and  children  is  treated  in  the  Department  of  Gyne- 
cology. 

Syphilis 

Syphilis  in  men.  women  and  children  is  receiving  attention  in  a  special 
clinic,  which  has  possibilities  of  development  as  outlined  above. 

The  laboratory  facilities  are  probably  adequate,  although  not  used  as 
freely  as  one  would  like  to  see.  This  is  due,  in  a  large  measure,  to  the  lack 
of  organization  and  correlation.  The  method  of  collecting  blood  specimens 
for  the  Wasserniann  test  by  means  of  a  capillary  tube  appears  to  be  decidedly 
obsolete,  and  the  requests  for  additional  specimens  seem  to  bear  out  this 
observation. 

The  follow-up  methods  are  not  bad  if  well  conducted.  Letters  or  notices 
are  sent  the  patients  that  fail  to  return.  Obviously,  three  letters  a  month 
apart,  and  then  reference  to  the  Health  Division  for  action,  cannot  be 
expected  to  function  for  the  benefit  of  the  patient  or  the  protection  of  the 
community. 

There  has  been  a  falling  off  in  the  volume  of  work  done  since  January, 
19*20,  which  we  believe  can  be  attributed  to  the  staff  personality  and  method 
of  handling  patients,  as  well  as  to  the  irregularity  of  time  of  arrival  and  de- 
parture of  the  doctors.  The  ""floating"  population,  the  clinic  hours,  the 
poor  arrangement  of  rooms,  lack  of  system  and  long  periods  of  waiting  are 
all  contributory  factors. 

RECOMMEND  A  TIONS 

It  is  recommended  that  better  management  be  instituted. 
That  gonorrhea  in  women  be  given  proper  consideration;  and, 

That,  because  of  the  present  need  and  the  indicated  future  growth,  the  clinic  be  open 
six  nights  a  week. 


410  Hospital  and  Health  Survey 

City  Hospital 

The  venereal  disease  service  of  the  City  Hospital  has  never  been  entirely 
satisfactory.  Gonorrhea  in  both  male  and  female  has  been  neglected,  and 
the  importance  of  the  urologic  and  gynecologic  services  has  not  been  recog- 
nized or  developed  to  a  degree  at  all  commensurate  with  the  city's  responsi- 
bility in  caring  for  the  individual. 

It  is  estimated  that  about  150  beds  will  be  required  in  making  adequate 
provision  for  the  venereal  disease  patients;  and  this  must  receive  considera- 
tion in  the  plans  for  the  reorganization  of  services  and  rebuilding  of  the  City 
Hospital.  In  general  it  may  be  said  that,  while  the  syphilis  service  as  main- 
tained prior  to  its  discontinuance  during  the  recurrence  of  influenza  in  Febru- 
ary and  March,  1920,  was  excellent,  and  the  quarters  in  which  the  depart- 
ment of  dermatology  was  housed  (in  a  remodeled  and  repaired  building)  are 
the  best,  in  the  present  City  Hospital  marked  improvement  is  required  to 
make  the  most  of  the  possibilities.  In  other  words,  nothing  short  of  a  new 
building  will  make  it  possible  to  provide  the  type  of  venereal  disease  service 
that  the  City  Hospital  of  Cleveland  should  maintain. 

Gonorrheal  service  for  women  can  be  rated  as  only  fair,  because  it  varies 
with  the  different  services;  while  the  gonorrheal  service  for  men  is  not 
satisfactory  and  is,  as  a  matter  of  fact,  neglected,  if  not  ignored. 

It  is  recommended  that  for  the  sake  of  the  future  development  of  venereal 
disease  service,  a  definite  plan  of  procedure  free  from  any  consideration  of 
professional  jealousy  or  controversy  on  the  part  of  the  staff  and  manage- 
ment, be  put  into  effect.  Two  possible  plans  may  be  considered:  one  a 
venereal  disease  service,  caring  for  all  cases  of  gonorrhea  and  syphilis  in  both 
sexes  of  all  ages,  under  one  member  of  the  staff  acting  as  chief  of  a  major 
hospital  service,  with  a  corps  of  associates  especially  trained  in  the  various 
ubdivisions  of  venereal  disease  treatment,  plus  a  cooperative  arrangement  for 
consultation  service  with  the  other  departments  of  the  hospital  organization; 
the  other  a  three-headed  service,  with  syphilis  assigned  to  dermatology, 
gonorrhea  in  the  male  to  urology,  and  gonorrhea  in  the  female  to  gynecology. 
In  this  second  scheme  of  organization  the  department  of  dermatology  as  now 
organized  should  continue  to  function  in  its  present  efficient  manner.  The 
urologist  and  gynecologist  must  have  a  full  service  under  the  surgical  division 
of  the  hospital  organization.  These  services  should  be  continuous  through- 
out the  year.  The  appointees  should  be  definitely  charged  with  the  respon- 
sibility of  caring  for  all  cases  of  gonococcal  infections,  both  acute  and  chronic, 
in  their  respective  fields,  and  at  the  same  time  charged  with  the  care  of  the 
surgical  work  properly  falling  within  the  domain  of  the  special  divisions  of 
urology  and  gynecology. 

DIVISION  OF  HEALTH 

Six  years  ago  the  Division  of  Health  outlined  a  campaign  for  the  control 
of  the  venereal  diseases.  One  of  the  things  proposed  under  this  campaign 
was  the  establishment  of  a  special  bureau  to  devote  its  energies  to  educa- 


Venereal      Disease  411 

tional  and  medical  work  and  particularly  to  the  reporting  of  cases.  This 
bureau  was  never  established;  reporting  has  not  been  stimulated  or  enforced; 
and  it  is  found  that  little  work  along  educational  lines  has  been  attempted. 
The  only  Division  of  Health  activity  is  the  laboratory  facility  mentioned 
as  a  special  topic  under  Diagnosis. 

During  the  war  certain  renewed  activity  was  stimulated  by  the  United 
States  Government  and  the  State  Board  of  Health.  Advantage  should  be 
taken  of  the  public  sentiment  then  developed,  and  the  continued  national 
campaign  should  be  used  as  the  foundation  upon  which  to  base  the  future 
activities  of  a  special  bureau  of  the  division.  This  can  be  done  in  such  a 
manner  that  the  confidence  of  the  medical  profession  will  be  regained  and 
retained.  The  general  public  not  only  needs  but  will  welcome  educational 
information.  The  only  educational  material  used  in  the  city  at  present  is 
provided  by  the  State  Health  Department. 

Theoretically,  one  of  the  important  functions  of  the  Division  of  Health 
in  controlling  exposure  to  syphilis  or  gonococcus  infection  is  to  warn  indi- 
viduals regarding  specific  sources  of  infection;  but  few  of  the  practical 
procedures  worked  out  for  other  infections  are  applicable  to  the  venereal 
diseases,  and  such  special  measures  as  are  being  tested  out  for  the  latter  are 
thus  far  limited  largely  to  what  may  be  accomplished  by  the  private  physician 
and  through  tactful  social  service  follow-up  among  the  families  and  intimate 
associates  of  infected  individuals.  Again,  personal  instruction  of  individuals 
likely  to  be  exposed  is  of  great  importance.  The  pupil  nurse,  for  example, 
who  is  about  to  assist  in  an  Operation  or  care  for  an  active  case  of  syphilis 
should  be  instructed  in  mechanical  and  antiseptic  methods  of  preventing 
infection  of  herself  or  others.  It  is  not  difficult  to  train  her  to  wear  rubber 
gloves,  to  wash  her  hands  thoroughly  with  soap  and  water,  to  avoid  touch- 
ing her  eyes  or  lips  with  her  hands,  and  to  use  such  antiseptics  as  may  be 
designated.  In  theory  it  is  just  as  possible  to  instruct  individuals  to  employ 
similar  methods  for  avoidance  of  genital  infection.  In  practice,  however, 
the  health  officer  as  well  as  the  physician  finds  himself  confronting  the  facts 
that  genital  exposure  to  venereal  infection  is  not  consciously  risked  within 
marriage,  and  that  exposure  outside  of  marriage  is  not  sanctioned  under 
any  conditions  by  American  public  opinion  or  by  law.  Consequently,  to 
undertake  popular  education  for  individual  prophylactic  measures  presents 
the  dilemma  of  over  emphasizing  the  importance  of  what  is  a  relatively 
small  number  of  cases  of  exposure  in  wedlock,  or  of  admitting  a  very  large 
number  of  violations  of  law  and  public  standards  of  morality  by  illicit  inter- 
course. 

Scientific  knowledge  exists  upon  which  have  been  based  useful  military 
measures  for  promptly  cleansing  exposed  surfaces  and  membranes  of  the 
body  and  applying  effective  antiseptics.*  As-  a  part  of  a  general  adminis- 
trative program  in  the  army,  where  all  the  men  can  be  required  under  mili- 

*The  essential  factors  in  the  procedure  generally  known  as  "medical  prophylaxis"  are:  the  appli- 
cation within  a  short  period  of  time  after  exposure  (preferably  within  an  hour)  of  mechanical  cleansing 
of  exposed  parts  with  soap  and  water;  the  administration  of  an  antiseptic  solution  to  the  urethral  and 
vaginal  mucous  membranes  for  protection  against  gonorrhea;  and  the  application  of  a  germicidal  oint- 
ment for  protection  against  syphilis. 


41  ^  Hospital  axq  Health  Survey 

tary  regulation  to  carry  out  instructions  given  them,  and  where  every  man 
must  be  taught  the  purpose  and  relative  importance  of  each  measure  in  the 
entire  program,  so-called  "medical  prophylaxis"  has  its  place.  In  civil  life 
to  achieve  the  same  results  even  among  those  who  could  be  reached,  it  would 
be  necessary  for  physicians  and  clinic  chiefs  to  advise  with  individuals,  who 
apply  to  them  immediately  after  exposure,  to  provide  adequate  supervision 
of  the  prophylactic  treatment  recommended  and  to  keep  in  touch  with  each 
individual  until  all  danger  of  infection  is  passed. 

The  difficulties  of  securing  such  administrative  efficiency,  and  the  dangers 
of  stimulating  undue  dependence  upon  prophylactic  measures  officially  recom- 
mended, have  prevented  the  development  of  practical  prophylactic  measures 
of  general  public  health  importance.  Furthermore,  the  promulgation  of 
such  measures  has  been  constantly  met  by  opposition  from  those  who  earnestly 
believe  that  popular  education  concerning  the  methods  and  the  places  where 
such  preventive  treatment  may  be  administered,  would  be  interpreted  as 
public  sanction  for  greater  sexual  promiscuity,  at  the  same  time  diverting 
popular  attention  from  the  larger  and  more  effective  preventive  measures  of 
the  program.  It  is  believed  that  prophylactic  measures  of  this  character 
are  of  relatively  slight  practical  importance  in  civil  life.  It  should  be  stated 
in  this  connection,  however,  that  this  applies  only  to  prophylactic  measures 
for  genital  exposures,  because  popular  opinion  holds  that  it  is  reasonable  to 
demand  that  individuals  protect  themselves  through  the  more  effective  and 
morally  far  more  desirable  measure  of  avoidance  of  any  exposure  through 
sexual  contact.  In  contrast,  public  opinion  fully  supports  and  laws  demand 
prophylactic  measures  for  prevention  of  the  development  of  gonococcus  in- 
fection of  the  eyes  of  new-born  children  exposed  by  passage  through  the 
infected  birth  canal  of  the  mother. 


RECOMMEND  A  TIONS 

It  is  recommended  that  the  Division  of  Health  establish  a  special  bureau  in  charge 
of  a  full-time  medical  officer,  with  the  needful  number  of  assistants  (such  as  nurses,  clerks, 
etc.),  to  conduct  properly  a  comprehensive  campaign  for  the  eradication  of  gonorrhea 
and  syphilis.  The  duties  of  such  a  bureau  should  be  the  organization,  the  supervision 
and  the  stimulation  of  treatment  facilities;  the  returning  to  treatment  of  those  patients 
who  fail  to  continue  under  medical  care  until  cured;  the  education  of  the  public  upon  the 
methods  of  contraction,  spread,  control,  prevention  and  treatment  of  veneral  diseases- 
The  duties  of  the  chief  of  this  bureau  in  completing  a  comprehensive  program  would  pre- 
clude any  clinical  work,  either  private  or  public.  In  order  to  gain  the  absolute  confidence 
of  the  medical  profession,  he  should  have  had  clinical  experience  in  the  treatment  of  the 
venereal  diseases,  and  he  should  not  be  required  or  permitted  to  do  clinical  work.  The 
following  plan  of  organization  for  the  venereal  disease  bureau  of  the  Division  of  Health  is 
suggested : 


Venereal      Disease  413 

Proposed  Organization  for  Venereal  Disease  Bureau  of  the 
Division  of  Health 

1  Chief  (full-time  physician). 

2  Nurses  (female). 
1  Agent  (male). 

1  Stenographer. 
1  Clerk. 

The  function  of  the  special  bureau  of  the  Division  of  Health  devoted 
to  the  combating  and  control  of  the  venereal  diseases  should  be  primarily 
educational — education  of  the  public  upon  the  general  subject  of  prevalence, 
mode  of  transmission,  serious  consequences  of  gonorrhea  and  syphilis,  and 
the  necessity  for  prompt  and  continuous  treatment.  This  educational  work 
must  reach  all  classes  and  ages  in  the  community,  directly  or  indirectly, 
through  lectures,  the  use  of  motion  pictures,  stereopticon  slides  and  pam- 
phlets and  other  means  of  printed  publicity. 

Special  educational  work  is  required  to  reach  the  physicians,  not  only 
for  the  purpose  of  arousing  their  interest  as  members  of  the  community  in 
the  campaign  for  the  combating  of  venereal  diseases,  but  also  to  develop  the 
professional  appreciation  of  the  necessity  for  better  diagnosis  and  more  con- 
scientious, continued  treatment.  An  active  campaign  along  strictly  pro- 
fessional lines  should  be  conducted  by  the  Division  of  Health  in  cooperation 
with  the  Academy  of  Medicine,  using  as  the  vehicle,  existing  motion  picture 
films  upon  the  modern  diagnosis  and  treatment  of  gonorrhea  and  syphilis, 
supplemented  by  such  printed  material  as  is  available  or  may  be  produced. 

An  efficient  campaign  of  this  character  will  stimulate  the  reporting  of 
gonorrhea  and  syphilis,  which  has  been  neglected  in  the  past.  The  adminis- 
trative function  of  the  Division  of  Health,  Bureau  of  Venereal  Diseases, 
should  include  the  education  and  stimulation  of  the  hospitals  of  Cleveland 
to  an  appreciation  of  the  necessity  for  bed  treatment  for  selected  cases,  the 
inspection  and  supervision  of  dispensaries  treating  gonorrhea  and  syphilis, 
and  the  stimulation  of  the  clinics  to  improve  continually  the  existing  facili- 
ties. Material  assistance  can  be  rendered  to  dispensaries  in  various  ways, 
and  the  City  Division  of  Health  should  act  not  only  as  the  stimulating 
agency  but  should  also  assume  the  function  of  intermediary  between  the  local 
clinic  and  the  state  and  federal  health  authorities.  The  state  subsidy,  both 
in  the  form  of  financial  aid  and  of  free  arsphenamine,  should  be  received  by 
the  department  and  distributed  to  the  approved  clinics.  The  reports  from 
the  various  clinics  can  be  consolidated  for  forwarding  to  the  proper  authori- 
ties. Provision  for  examination,  diagnosis  and  treatment  of  cases  requiring 
control  should  be  made  by  the  City  Division  of  Health.  Quarantine  of  those 
individuals  unwilling  or  unable  to  protect  the  community  must  be  assumed 
by  the  Division  of  Health,  and  its  facilities  should  be  so  adjusted  that  they 
may  be  available  for  the  private  practitioner,  clinic,  hospital  and  the  court. 


414  Hospital  and  Health  Survey 

Various  social  measures  come  within  the  function  of  the  Venereal  Disease 
Bureau  of  the  Division  of  Health  through  its  close  cooperation  with  courts, 
clinics,  physicians  and  the  organizations  represented  in  the  Welfare  Federa- 
tion. A  standard  method  of  follow-up  should  be  developed,  and  it  is  recom- 
mended that  some  series  of  forms  similar  to  that  suggested  in  the  following 
recommendation  be  used  for  both  publicly  and  privately  treated  individuals. 
Full  use  should  be  made  of,  and  thorough  cooperation  given  by  the  Division 
of  Health  to  the  social  service  machinery  of  the  city,  whether  this  be  through 
a  central  organization  serving  all  the  hospitals,  clinics  and  physicians  of 
Cleveland,  or  through  the  social  service  departments  of  the  individual  insti- 
tutions. 

The  duties  of  the  chief  should  be  to  direct  the  general  activities  of  the 
bureau,  to  inspect  the  diagnostic  and  treatment  facilities  throughout  the 
city,  to  stimulate  greater  activity  and  improve  the  efficiency  of  all  the  agen- 
ices  engaged  in  the  combating  and  control  of  the  venereal  diseases,  to  main- 
tain close  cooperative  arrangements  with  state  and  federal  agencies,  both 
public  and  voluntary,  and,  finally,  to  institute  such  new  procedure  as  may 
be  required  from  time  to  time. 

The  duties  of  the  nurses  should  be  to  aid  and  inspect  follow-up  work, 
to  assist  in  the  transferring  of  patients  from  hospital  to  clinic  or  vice  versa, 
to  cooperate  with  the  probation  officers,  and  to  assist  in  the  various  activi- 
ties connected  with  the  work  of  the  courts. 

The  duties  of  the  agent  should  be  to  placard  the  city,  check  drug  store 
prescribing,  investigate  the  advertising  and  non-advertising  medical  charla- 
tan, and  carry  on  such  other  activities  as  call  for  the  services  of  a  non-medical 
male  employe. 

The  duties  of  the  stenographer  and  clerk  should  be  the  ordinary  activity 
of  routine  office  work. 

The  Division  of  Health  should  prepare  and  provide  the  printed  material 
for  educational  and  follow-up  work  required  by  dispensaries  that  treat 
venereal  diseases.     Details  of  a  follow-up  plan  are  outlined  below: 

Follow-up 

To  control  the  spread  and  prevent  the  future  development  of  disastrous 
sequelae  of  gonorrhea  and  syphilis,  continued  effort  must  be  made  by  the 
Division  of  Health,  physicians,  clinics  and  drug  stores,  to  the  end  that  the 
patients  understand  the  necessity  for  uninterrupted  treatment  and  observa- 
tion until  pronounced  cured  by  the  physician.  This  can  be  accomplished 
by  the  judicious  use  of  educational  material,  such  as  public  lectures,  pam- 
phlets, posters,  and  the  like,  coupled  with  the  institution  of  the  most  modern 
therapeutic  procedures  in  clean,  orderly  and  generally  well-maintained  treat- 
ment quarters — all  coordinated  with  broad  human  understanding  by  a 
trained  physician,  who,  realizing  his  responsibility,  carefully  explains  to  each 
patient,  at  the  first  visit,  the  serious  nature  of  the  complaint  and  empha- 
sizes the  necessity  of  conscientious,  continued  treatment. 


V-E  NEREAL        DISEASE  415 

Some  infected  individuals  need  to  be  brought  to  a  forceful  realization  of 
their  personal  or  public  responsibilities  with  regard  to  communicable  dis- 
eases. For  their  benefit  the  Division  of  Health  must  be  prepared  to  meet 
its  own  responsibility  and,  in  cooperation  with  the  physician  in  either  his 
private  practice  or  clinic  service,  should  arrange  methods  of  varying  degree 
for  the  purpose  of  again  placing  the  delinquent  patient  under  treatment. 

A  simple  "request"  card  has  been  found  efficient  in  a  number  of  clinics, 
and  has  also  been  used  by  physicians  in  their  private  practice.  These  cards 
are  sent  out  in  sealed  envelopes  as  first  class  mail. 


Mr _ _ 

: _ No. 


You  are  requested  to  return  on  or  before _ 

You  were  not  cured  at  your  last  visit. 

You  need  further  treatment  or  observation. 

For  youi  own  good  and  the  protection  of  others  this  card  is  sent  to  you. 

Kindly  answer  this  note. 

M.  D. 


Upon  receiving  no  response  to  these  calls  for  more  active  measures,  the 
use  of  the  following  form  is  suggested: 


Mr 

: No... 

You  were  requested  to  return  on  or  before 

Will  you  return  on 

You  were  not  cured  at  your  last  visit. 

You  failed  to  keep  this  appointment  or  to  notify  us  in  any  way.  If  you 
are  under  competent  medical  care,  we  are  satisfied.  Failure  to  notify  us  of 
your  present  arrangements  for  medical  care  will  force  us  to  report  you  to  the 
Division  of  Health. 

For  your  own  good  and  the  protection  of  others  this  card  is  sent  to  you. 

Kindly  answer  this  note. 

M.  D. 


416  Hospital  and  Health  Survey 

The  third  form  should  be  a  final  notice  that,  unless  the  individual  return 
for  treatment,  his  or  her  name  and  address  will  be  reported  on  a  certain  date 
to  the  Division  of  Health,  in  compl  ance  with  the  law.  Two  extra  blanks 
will  be  required  for  reports  to  the  Division  of  Health :  one  for  the  physician 
to  report  his  patient  under  treatment  elsewhere,  and  one  to  report  failure 
of  his  patient  to  return  for  treatment. 

Any  efficient  plan  for  holding  individuals  to  prolonged  periods  of  treat- 
ment and  observation  requires  that  patients  be  educated  to  the  end  that 
they  understand  the  need  for  continued  treatment;  the  advisability  of  notify- 
ing the  doctor  when  unable  to  keep  an  appointment;  the  real  power  possessed 
by  the  Division  of  Health;  and,  finally,  the  likelihood  of  action  by  the 
clinic  or  physician  should  circumstances  demand  force. 

Equally  necessary  to  make  any  "follow-up"  notification  efficient  is  the 
proper  timing  of  the  notices.  The  first  notice  ought  never  to  be  delayed 
more  than  a  week  after  the  first  neglected  appointment;  the  second  notice 
must  go  out,  if  it  is  to  carry  weight,  on  the  day  of  the  unkept  new  appoint- 
ment; and  the  third  highly  official  notice  should  be  timed  for  not  more  than 
a  week  later.  The  Division  of  Health,  upon  receipt  of  notice  of  discontinu- 
ance of  treatment,  should  begin  official  action  by  sending  its  inspector 
promptly  to  visit  the  patient  for  the  purpose  of  persuading  the  individual  to 
return  to  treatment.  If  the  patient  does  not  respond  to  persuasive  methods, 
quarantine  or  isolation  should  be  enforced. 

The  Division  of  Health  should  establish  rules  and  regulations  prescribing 
minimum  requirements  for  the  conduct  of  dispensaries  that  treat  gonorrhea 
and  syphilis.     (See  page  417.) 

The  Division  of  Health  should  be  guided  in  its  activities  by  an  advisory 
council  or  committee  on  venereal  diseases,  appointed  by  the  Commissioner. 


Rules  and  Regulations  Governing  the  Conduct  and  Maintenance 

of  Laboratories 

Rules  and  regulations  governing  the  conduct  and  maintenance  of  labora- 
tories that  offer  facilities  for  the  diagnosis  of  gonorrhea  and  syphilis  should 
be  formulated  by  the  Division  of  Health.  These  rules  should  apply  in 
general  to  the  entire  field  of  infectious  diseases.  The  lack  of  supervision  by 
the  Division  of  Health  over  private,  hospital  and  commercial  laboratories 
is  undoubtedly  a  weak  link  in  the  general  problem  of  venereal  disease  control. 

The  Sanitary  Code  should  have  a  section  stating  that  all  laboratories  in 
Cleveland  that  offer  facilities  for  the  diagnosis  of  communicable  diseases 
shall  not  be  conducted  or  maintained  without  a  permit  issued  by  the  Divi- 
sion of  Health,  or  otherwise  than  in  accordance  with  the  regulations.  The 
regulations  should  provide  for: 

1.  Applications  for  permits  to  conduct  and  maintain  laboratories. 

2.  Duly  qualified  persons  to  be  in  charge. 


Venereal      Disease  417 


3.  Proper  handling  of  specimens  received  at  the  laboratory  by  a  method  of 
numbering  and  designation  that  will  definitely  establish  the  identity  of 
each  particular  specimen  in  order  that  errors  may  be  avoided. 

4.  Proper  records  covering  the  following  points: 

(a)  Laboratory  number  and  date  of  receipt  of  specimen. 

(b)  Name  and  address  of  the  person  from  whom  the  specimen  was 
taken,  or  some  symbol  possible  for  identification. 

(c)  Name  and  address  of  the  person  to  whom  the  report  of  the  result 
was  made. 

(d)  Finally,  the  result  of  the  test 

The  records  should  be  available  for  inspection  by  the  duly  authorized 
Division  of  Health  representative. 

5.  Establishment  of  reasonable  minimum  requirements  in  order  to  safeguard 
the  provision  of  adequate  facilities  for  the  proper  performance  of  the  test 
undertaken  by  the  laboratory.  In  line  with  this  should  be  some  definite 
recognition  of  a  reasonable  method  of  procedure. 

Rules  and  Regulations  Governing  Dispensaries 

Rules  and  regulations  should  be  formulated' under  the  Sanitary  Code  to 
govern  dispensaries  wherein  communicable  diseases  are  treated  or  diagnosed; 
so  that  they  shall  not  be  conducted  and  maintained  without  control  and 
supervision  of  the  Division  of  Health.  Rules  governing  the  conduct  of  dis- 
pensaries for  the  treatment  of  persons  afflicted  with  syphilis  or  gonorrhea 
may  be  divided  into  two  divisions: 

Syphilis 
Regulations  for  the  treatment  of  syphilis  should  provide  for : 

1.  A  special  department  that  shall  be  responsible  for  the  care  of  all  indi- 
viduals that  come  to  the  dispensary  infected  with  syphilis,  with  the  pro- 
yiso  that  when  the  nature  of  the  part  affected  requires  treatment  in  some 
other  department  of  the  dispensary,  treatment  may  be  given  jointly  by 
the  two  departments. 

2.  Microscopic  examinations  of  suspected  lesions  by  the  syphilis  depart- 
ment. 

3.  Laboratory  facilities  for  making  Wassermann  tests  in  the  dispensary,  or 
the  use  of  the  Division  of  Health  laboratory  or  other  approved  labora- 
tories. 

4.  Prompt,  intensive  treatment,  by  the  use  of  salvarsan,  mercury,  or  other 
accepted  means  of  treatment  in  sufficient  quantities  in  all  cases  of  syphilis. 
In  order  to  fulfill  the  public  health  function,  the  clinic  must  be  made  to 
appreciate  its  obligation  to  render  an  infected  person  non-communicable 
at  the  earliest  possible  moment. 


418  Hospital  and  Health  Survey 

5.  Regulation  of  the  number  of  patients  to  be  treated,  in  order  to  overcome 
crowding  and  the  reduction  of  efficient  service  to  the  patient  and,  there- 
fore, to  the  community.  From  experience  throughout  the  country,  it  is 
generally  conceded  that  the  maximum  number  of  patients  to  be  treated 
by  a  clinic  should  be  limited  and  not  exceed  ten   an  hour   per  physician. 

6.  Complete  and  adequate  records.  These  are  of  primary  importance  to 
the  successful  conduct  of  a  dispensary,  and  should  be,  in  so  far  as  possible, 
standardized  and  made  available  for  the  approved  clinics. 

7.  Maintenance  of  a  follow-up  system  according  to  a  plan  approved  by  the 
Division  of  Health,  in  order  to  insure  regular  attendance. 

8.  A  standard  procedure  providing  for  the  discharge  of  patients,  to  include 
test  and  subsequent  observation. 

9.  Having  dispensaries  open  at  least  three  days  a  week,  preferably  during 
evening  hours  on  at  least  two  days. 

Gonorrhea 
Regulations  for  the  treatment  of  gonorrhea  should  provide  for: 

1 .  Systematic  microscopic  examination  of  all  discharges  in  every  department 
of  the  dispensary  wherein  any  person  is  treated. 

2.  Provision  for  and  employment  of  proper  facilities  for  asepsis  and  antisepsis. 

3.  Facilities  for  urethroscopic  and  cystoscopic  examination  to  be  regularly 
employed  by  the  physicians  in  attendance. 

4.  The  use  of  complement-fixation  test  for  gonorrhea.  It  is  deemed  advis- 
able to  recommend  this,  although  this  test  is  not  as  yet  thoroughly  estab- 
lished in  medical  practice. 

5.  6,  7,  8  and  9  are  the  same  as  for  syphilis. 


Venereal      Disease  419 


III.      Legal  Aspects 

THIS  Survey  is  concerned  not  only  with  what  Cleveland  is  doing  and 
should  do  to  detect,  diagnose  and  treat  venereal  disease,  it  is  even 
more  vitally  concerned  with  what  Cleveland  is  doing  and  should  do 
to  prevent,  detect,  diagnose  and  treat  sex  delinquency,  as  the  cause  of 
venereal  disease. 

The  analogy  is  a  fair  one,  because  prostitution  and  other  forms  of  sex 
delinquency  are  certainly  diseases  of  society  and  require  the  application  of 
the  best  social  science  for  their  amelioration. 

Laws  relating  to  sex  delinquency  follow  the  outlines  of  the  average  medi- 
cal text  book.  They  define  and  name  each  disease  or  offense,  provide  sani- 
tary measures  in  the  shape  of  decent  environments,  describe  the  symptoms 
of  each  disease  in  terms  of  human  conduct,  provide  for  the  early  detection 
of  those  symptoms  by  the  police,  the  diagnosis  in  the  verdict  of  the  jury, 
and  the  treatment  in  the  sentence  of  the  court. 

Much  other  machinery  necessary  in  one  or  the  other  of  these  processes, 
such  as  prosecutors,  probation  officers,  psychiatrists,  jails,  detention  houses, 
reformatories  and  feeble-minded  colonies,  require  the  sanction  and  support 
of  laws  to  operate. 

It  is  fairly  obvious,  therefore,  that  a  consideration  of  the  laws  on  this 
subject  is  of  first  importance. 

The  Legal  Section  of  this  Survey  will  attempt  to  cover  Cleveland's  laws 
or  sex  delinquency  and  some  of  the  machinery  for  their  enforcement. 

The  relation  of  sex  delinquency  laws  and  their  enforcement  to  venereal 
disease  is  the  relation  of  cause  and  effect  in  the  inverse  ratio.  This  is  true, 
because  the  aim  of  such  laws  is  to  prevent  sexual  relations  outside  marriage, 
and  such  relations  are  known  to  be  the  immediate  or  ultimate  source  of 
most  venereal  disease. 

If  we  could  devise  100%  perfect  laws  prohibiting  extra  marital  relations, 
and  have  them  enforced  with  100%  efficiency,  venereal  disease  would  after 
a  while  disappear. 

No  community  has  been  found,  however,  and  probably  none  will  ever  be 
found  in  this  country,  willing  to  undergo  the  paternalistic  supervision  and 
to  make  the  sacrifice  of  personal  liberty,  necessary  to  accomplish  this  result 
solely  by  repressive  measures. 

Religion  and  education  will  and  should  be  relied  upon  to  penetrate  and 
influence  the  more  intimate  and  private  lives  and  standards  of  the  people. 

The  sexual  conduct  of  the  individual  becomes  a  matter  of  public  concern 
and  therefore  of  legal  regulation,  only  when  it  seriously  affects  the  sanction 
of  monogamous  marriage,  or  the  integrity  of  the  family,  or  the  public  health. 


J-'-iO  Hospital  axd  Health  Survey 

From  all  three  points  of  view,  the  niost  serious  menace  to  the  public  wel- 
fare in  sexual  conduct,  is  promiscuity.  From  the  public  health  point  of  view 
promiscuity  may  fairly  be  said  to  cause  the  vast  majority  of  all  venereal 
disease. 

That  female  is  the  most  dangerous  of  sex  delinquent  women  who  is  most 
promiscuous,  because  she  is  most  likely  to  be  diseased  and  to  transmit  dis- 
ease, and  this  regardless  of  whether  she  demands  money  or  its  equivalent 
or  not. 

Similarly,  the  male  who  most  frequently  consorts  with  promiscuous 
females  is  the  most  dangerous  of  sex  delinquent  males.  In  fact,  this  type 
of  male  is  probably  a  greater  menace  to  public  health  than  the  promiscuous 
female,  because  he  is  the  immediate  source  of  many  infections  of  innocent 
wives  and  children,  in  addition  to  infecting  the  other  women  with  whom  he 
consorts. 

It  was  because  prostitutes  have  always  been  the  most  promiscuous  per- 
sons of  either  sex  that  laws  aimed  at  their  activities  and  the  activities  of 
the  third  parties  who  promoted  or  exploited  prostitution  have  been  passed 
nearly  everywhere  in  this  country  and  have  found  a  large  measure  of  public 
support. 

AYhile  the  enforcement  of  such  laws  has  eliminated  red  light  districts 
and  open  houses  of  prostitution,  and  has  greatly  reduced  the  total  number 
of  contacts  of  prostitutes  and,  consequently,  the  amount-  of  disease  that 
they  spread,  these  laws  have  yet  failed  to  accomplish  the  results  which  we 
have  a  right  to  expect  from  the  expenditure  of  so  much  time  and  money  on 
their  enforcement. 

The  reason  is  not  far  to  seek.  Until  1919,  when  a  standard  form  of  law 
on  this  subject  was  prepared  and  presented  to  the  legislatures  of  the  several 
states  by  the  Federal  Government,  prostitution  was,  with  few  exceptions, 
an  offense  for  which  a  female  only  could  be  held  guilty. 

Generally  speaking,  also,  the  acceptance  of  money  by  the  prostitute  was 
a  necessary  ingredient  of  her  offense. 

It  is  axiomatic  that,  as  long  as  men  can  with  impunity  buy  such  services 
from  women,  there  will  always  be  found  women,  foolish,  ignorant  or  lazy 
enough  to  adopt  this  apparently  easy  way  out  of  life's  difficulties. 

Furthermore,  as  the  life  of  the  professional  prostitute  becomes  more  and 
more  hazardous,  many  of  them  are  forced  to  go  to  work,  and  the  amateurs 
are  retaining  their  jobs  for  the  same  reason.  Under  the  disguise  of  honest 
working  girls  many  such  women  are  supplementing  their  incomes,  or  secur- 
ing the  luxuries  which  they  think  are  necessary  to  them,  by  building  up  what 
they  fondly  believe  to  be  a  select  clientele. 

They  are  careful  when  taking  a  new  customer  not  to  ask  for  or  take 
money.  They  very  often  accept  gifts  of  jewelry  or  wearing  apparel,  theatre 
parties  or  expensive  meals,  either  as  a  test  or  as  a  real  quid  pro  quo. 


Venereal      Disease  _  421 

How  far  the  activities  of  such  amateur  prostitutes  make  up  for  the  reduc- 
tion in  the  activities  of  the  professionals  no  one  knows.  The  doctors  testify, 
however,  that  a  large  number  of  their  men  patients  claim  to  have  been 
infected  by  such  amateurs. 

It  became  obvious,  therefore,  if  further  progress  was  to  be  made,  that 
the  definition  of  prostitution  would  have  to  be  enlarged  to  include  all  males 
whose  payments  make  prostitution  possible,  and  all  males  and  females 
sexually  indiscriminate,  even  though  the  element  of  hire,  which  usually 
exists  in  some  form,  could  not  be  proven. 

Following  the  recommendation  of  the  Federal  Government  in  this  regard 
the  legislatures  of  eleven  states,  in  1919,  remodeled  their  prostitution  laws. 
Ohio  was  one  of  these  eleven  states,  and  has  therefore  had  since  June  21, 
1919,  the  best  law  on  prostitution  (except  for  paragraph  C  under  subsection 
17)  that  sound  social  experience  has  yet  been  able  to  devise.  This  law 
amends  Section  13031  of  the  General  Code  by  adding  seven  new  subsections, 
13  to  19,  inclusive. 

This  law  not  only  attempts  to  reach  all  promiscuous  sex  delinquents 
but  sharpens  and  renders  more  serviceable  the  legal  weapons  against  the 
third  parties  to  prostitution,  particularly  the  taxicab  chauffeur,  that  most 
modern  and  elusive  of  go-betweens. 

It  is  suggested,  however,  that  paragraph  C  of  subsection  17  of  this  law 
be 'amended  to  read  as  follows: 

The  name  and  place  of  detention  of  any  person  charged  with  a  violation 
of  Section  13031-13  of  the  General  Code  shall  immediately  be  reported  in 
writing  to  the  district  or  city  board  of  health  by  the  department  making  the 
arrest. 

No  person  so  charged  shall  be  discharged  from  custody  on  bail  or  other- 
wise until  12  hours  after  the  receipt  by  such  district  or  city  health  board  of  the 
name  and  place  of  detention  of  such  person  so  charged. 

It  shall  thereupon  be  the  duty  of  such  district  or  city  health  board  to 
determine  forthwith  whether  there  are  reasonable  grounds  for  believing  that 
such  person  is  infected  with  a  venereal  disease,  or  has  been  exposed  thereto. 

If  such  district  or  city  health  board  shall  determine  that  such  reasonable 
grounds  exist,  it  shall  be  the  duty  of  such  board  to  cause  such  person  to  be 
examined  immediately  for  such  venereal  disease,  by  a  physician  competent 
to  determine  the  existence  of  such  disease. 

In  order  to  make  the  findings  above  outlined,  the  district  or  city  board  of 
health  shall  have  the  power  to  detain  any  such  person  so  charged  for  a 
period  not  exceeding  48  hours,  after  expiration  of  the  12  hours  following  the 
receipt  by  such  board  of  the  notice  from  the  department  making  the  arrest. 

Any  such  person  found  to  have  a  venereal  disease  in  an  infectious  form 
shall  be  treated  under  quarantine,  at  a  clinic,  or  otherwise,  as  such  district 
or  city  health  board  may  determine  shall  best  protect  the,  public  health. 


422  Hospital  and  Health  Survey 

Such  infected  person  shall  pay  for  such  treatment,  if  able  to  do  so,  but 
if  not,  such  medical  treatment  shall  be  at  the  expense  of  the  municipality  or 
county. 

The  purpose  of  this  amendment  is  to  separate  the  detection,  diagnosis 
and  treatment  of  venereal  disease,  from  the  detection,  diagnosis  and  treat- 
ment of  delinquency.  Experience  has  shown  again  and  again  that  police 
and  courts  are  confused  and  diverted  from  the  solution  of  the  problem  of 
delinquency  with  which  they  are  charged,  by  imposing  medical  or  quasi- 
medicalj  duties  upon  them.  Furthermore,  this  mixing  of  venereal  disease 
and  delinquency  is  not  in  the  best  interest  of  public  health. 

Under  this  act,  as  it  now  exists,  the  judge  can  have  in  many  cases  no 
basis  for  issuing  or  withholding  the  order  for  medical  examination.  This 
basis  is,  as  suggested  in  the  proposed  amendment,  a  reasonable  ground  for 
believing  that  the  defendant  is  infected  or  has  been  exposed  to  infection. 
The  mere  fact  that  the  defendant  is  charged  with  a  violation  of  Section 
13031-13  would  be  wholly  inconclusive  in  many  cases  from  a  legal  point  of 
view. 

Suppose  the  defendant  was  charged  with  soliciting,  procuring  or  trans- 
porting for  prostitution — all  offenses  which  do  not  involve  proof  of  sexual 
contact  to  constitute  the  offense.  In  the  exercise  of  his  discretion,  the  aver- 
age judge  might  well  conclude  that  no  justification  exists  for  compulsory 
examniation  in  such  cases,  whereas  the  physician  would  see  on  the  faces 
of  many  such  defendants  the  clinical  evidence  or  stigmata  of  their  disease. 
Furthermore,  evidence  of  exposure  to  disease,  which  has  no  bearing  what- 
ever on  the  defendant's  guilt  or  innocence  of  the  crime  charged,  could  be 
heard  by  the  health  authorities,  but  not  by  the  courts. 

It  is  believed,  therefore,  that  some  such  procedure  as  that  suggested  in 
the  proposed  amendment  would  much  better  serve  the  interests  of  both 
courts  and  health  departments. 

There  is  one  type  of  disease,  however,  that  is  known  to  have  a  direct 
and  vital  bearing  upon  delinquency,  and  that  is  mental  disease. 

So  many  careful  and  authoritative  studies  have  been  made  of  this  rela- 
tion between  delinquency  and  mental  defectiveness  that  it  may  be  taken 
as  settled  that  from  20%  to  50%  of  sex  delinquents  are  mentally  defective, 
and  will  not  be  benefited  by  the  ordinary  dispositions  of  such  cases  made 
by  the  courts. 

The  law  for  the  diagnosis  and  treatment  of  mental  defectives  should  be 
amended  so  as  to  make  available  to  every  Cleveland  court,  juvenile  and  adult, 
which  handles  sex  delinquent  cases,  competent  and  adequate  psychiatric 
service  for  the  routine  mental  examination  of  all  such  delinquents,  prior  to 
sentence  by  the  court. 

Unless  this  be  done,  Cleveland  may  expect  to  see  a  procession  of  non- 
reformable  sex  delinquents  returning  again  and  again  to  its  reformatories, 
and  see  its  probation   officers   struggling  vainly  to   control  the  conduct  of 


Venereal      Disease  423 

feeble-minded  prostitutes  who  are  spreading  disease  broadcast,  and  who 
would  never  have  been  put  on  probation  had  their  true  mental  condition 
been  known. 

The  older  penal  statutes  of  Ohio  go  still  further  and  prohibit  couples  from 
indulging  in  habitual  fornication  or  adultery.  To  the  extent  that  such 
couples  remain  true  to  each  other  and  avoid  promiscuity,  they  may  be  said 
not  to  constitute  a  serious  public  health  problem. 

Ohio  also  has  the  injunction  and  abatement  law,  which  enables  the  prose- 
cuting attorney  or  any  citizen  of  the  county  to  enjoin  perpetually  the  use  of 
any  property  for  purposes  of  lewdness,  assignation  or  prostitution,  and  abate 
the  same  as  a  public  nuisance.     (Approved  March  30,  1917.) 

This  law  exists  in  39  other  states  and  has  been  found  extremely  valuable 
in  preventing  unlawful  use  as  houses  of  prostitution,  of  hotels,  rooming 
houses  or  apartments,  against  whose  owners,  managers,  or  lessees  it  was 
difficult  or  impossible  to  prove  violations  of  the  criminal  laws. 

Such  owners,  managers  or  lessees  of  property  have  often  been  so  politi- 
cally intrenched  that  officials  have  not  dared  to  move  against  them.  For 
this  reason  the  provision  in  such  laws  that  individual  citizens  could  bring 
such  injunction  and  abatement  suits  has  been  found  particularly  valuable. 

It  is  in  this  last  provision  that  the  Ohio  Injunction  and  Abatement  Law 
is  defective.  The  Ohio  legislators,  in  an  apparent  desire  to  protect  property 
owners  from  frivolous  suits,  have  so  hedged  about  the  right  of  a  citizen  to 
bring  such  suits  with  burdensome  and  unnecessary  restrictions  and  penal- 
ties, as  to  operate  as  a  practical  prohibition  of  this  sort  of  activity  by  a 
private  citizen  in  the  public  interest. 

Experience  in  all  other  states,  whose  laws  do  not  contain  these  restric- 
tions, proves  conclusively  that  they  are  unnecessary  and  that  the  fears  of 
the  Ohio  legislators  were  groundless. 

It  is  suggested,  therefore,  that  section  3  of  this  law,  approved  March  30, 
1917,  be  amended  by  omitting  the  last  half  of  the  section,  so  as  to  read  as 
follows : 

Whenever  a  nuisance  exists  the  attorney  general  of  the  state,  the  prose- 
cuting attorney  of  the  county,  any  person  who  is  a  citizen  of  the  county,  or 
any  organization  of  citizens  of  the  county  may  bring  an  action  in  equity  in 
the  name  of  the  state  of  Ohio,  upon  the  relation  of  such  attorney  general, 
prosecuting  attorney,  person  or  organization  to  abate  such  nuisance,  and  to 
perpetually  enjoin  the  person  or  persons  maintaining  the  same  from  further 
maintenance  thereof. 

The  laws  against  so-called  White  Slavery,  Keeping  Disorderly  Houses 
and  Rape  appear  to  be  adequate.  The  "age  of  consent"  law  should  be 
amended  to  protect  young  boys  as  well  as  girls  under  16,  and  more  protec- 
tion should  be  given  to  mental  defectives  generally.     It  is  believed,  however, 


424  Hospital  and  Health  Survey 

that  the  best  protection  to  such  mental  defectives  is  afforded  by  laws  which 
provide  for  early  registration,  and  supervision  inside  or  outside  institutions, 
of  this  class  of  individuals. 

Cleveland's  ordinances  providing  licensing  and  supervision  of  commer- 
cialized amusements,  such  as  dance  halls  and  pool  parlors,  are  well  in  the 
van  of  such  legislation,  particularly  the  one  relating  to  pool  parlors.  The 
state  law  for  the  licensing  and  supervision  of  hotels  (defined  to  include  most 
transient  rooming  houses)  and  restaurants  is  adequate.  It  would  help  if 
this  law  could  be  extended  to  apartment  houses.  There  should  be,  however, 
a  law  or  ordinance  providing  for  the  revocation  of  licenses  of  chauffeurs  who 
agree  to  act  as  go-betweens  for  prostitution. 

This  study  of  the  laws  indicates  that  Cleveland,  in  the  main,  is  legally 
well  equipped  for  the  prevention,  detection  and  diagnosis  of  delinquency, 
except  in  cases  of  mental  defectives.  Let  us  turn  to  a  consideration  of  the 
administrative  machinery  for  carrying  out  these  laws. 

ADMINISTRATION 

The  real  functions  of  police  and  courts  are,  in  the  modern  view,  the  pre- 
vention and  cure  of  crime  and  delinquency.  The  old  emphasis  on  detection 
after  the  crime  was  committed,  and  punishment  as  a  satisfaction  to  society 
is  giving  way  to  a  more  intelligent  and  humanitarian  doctrine.  Cleveland 
has  in  its  ordinances  for  licensing  and  supervising  commercialized  amuse- 
ments, and  in  its  state  law  treating  hotels,  transient  rooming  and  boarding 
houses  and  restaurants  in  the  same  manner,  legislation  of  this  preventive 
character.  The  inspection  of  these  different  sorts  of  places  is  scattered  among 
several  departments,  such  as  the  Mayor's  inspector  of  dance  halls,  the  Direc- 
tor of  Finance's  billiard  hall  inspector  and  the  hotel  inspectors  of  the  State 
Fire  Marshal. 

These  laws  and  ordinances  all  provide  for  .the  revocation  of  licenses  or 
closing  such  places  for  disorderly  or  immoral  conduct  on  the  premises. 

If  the  previous  recommendations  regarding  licensing  and  inspection  of 
apartment  houses  and  chauffeurs  are  adopted,  there  will  exist  two  more 
types  of  inspection  to  be  made  with  inspectors  probably  from  one  or  more 
departments.  It  is  believed  that  much  of  this  routine  inspection  could  be 
covered  by  a  special  women's  bureau  of  the  police  department,  with  econ- 
omy to  the  city  and  state  and  with  advantage  to  the  public  welfare  in  the 
prevention  of  crime. 

The  officers  of  this  bureau  could  be  deputized  by  the  departments  now 
charged  with  this  duty,  if  by  reason  of  the  other  structural  and  technical 
points  to  be  covered  by  such  inspections,  it  is  not  deemed  wise  to  turn  over 
the  entire  inspection  to  this  women's  bureau. 

Such  a  bureau,  having  access  to  police  information  and  becoming  ac- 
quainted with  criminals  and  delinquents,  would  be  in  a  much  better  position 
to  prevent  such  places  from  becoming  the  resorts  of  disorderly  characters 
than  could  the  inspectors  of  departments  not  so  acquainted  with  the 
underworld  of  a  large  city. 


Venereal      Disease  425 

Such  women  police  could  also  protect  girls  who  are  employed  at  such 
places  by  insisting  on  the  establishment  and  maintenance  of  proper  rules 
and  regulations.  In  addition  to  these  inspection  duties,  experience  in 
many  cities  where  women  police  are  employed  has  proven  their  value  as 
street  and  park  patrols,  and  in  the  investigation  and  adjustment  of  all  sorts 
of  home  and  employment  conditions  of  girls  who  are  either  delinquent  or 
in  great  danger  of  becoming  so. 

Finally,  there  exists  in  many  cities,  including  Cleveland,  a  hiatus  in  official 
case  work  with  girls,  between  purely  protective  work  and  probation  work. 
The  Cleveland  Municipal  Court  Act  (Sec.  1579-50)  provides,  for  instance, 
that  probation  officers  "shall  devote  their  time  to  the  interests  of  persons 
placed  on  probation."  The  girl  who  has  been  arrested  for  a  sex  offense  in 
this  court  has  no  one  officially  interested  in  her,  until  she  has  been  tried, 
convicted  and  sentenced.  When  she  has  at  last  arrived  at  this  stage  in  her 
travels  through  the  legal  machinery,  she  is  apt  to  be  hardened  or  bitter, 
and  experience  shows  that  she  is  infinitely  more  difficult  to  influence  and 
handle  then  than  immediately  after  her  arrest. 

A  sympathetic  and  intelligent  woman  police  officer,  with  social  experience, 
can  learn  the  truth  from  such  a  girl,  investigate  her  environment,  shield  her 
from  unnecessary  repetitions  of  her  story  and  bad  associations  pending  trial, 
see  to  it  that  she  is  mentally  and  physically  examined,  and  be  of  infinite 
value  to  the  prosecutor  and  judge  in  the  trial  and  disposition  of  the  case. 
She  may  even,  as  is  done  in  one  large  city,  prevent  a  charge  being  filed  against 
her  if,  after  informal  consultation  with  the  prosecutor  and  the  judge,  such  a 
course  seems  best  for  the  girl  and  society. 

It  goes  without  saying  that  on  the  personnel  of  such  a  bureau  everything 
depends.  To  secure  the  right  type  of  women  it  would  be  necessary  to  pay 
the  chief  inspector  at  least  $2,00*0,  and  the  others  from  $1,200  to  $1,800. 

It  is  our  opinion  that  most  harmony  and  efficiency  will  result  if  this 
bureau  is  made  a  part  of  the  police  department,  responsible  to  its  chief. 
The  contact  with  the  delinquents  would  be  much  closer  thereby,  and  no 
jealousy  between  the  men  and  women  police  officers  need  result,  if  it  is  made 
clear  from  the  beginning  that  all  credit  for  arrests  belongs  to  the  men  and 
that  the  women  derive  their  credit  from  the  amount  of  real  help  they  can 
give. 

Further  details  concerning  such  bureaus  can  be  learned  from  the  head 
of  one  of  the  most  progressive  and  effective  of  them,  in  Washington,  D.  C. 

If  it  be  argued  that  much  of  this  work  is  now  being  done  in  Cleveland 
by  the  private  unofficial  Woman's  Protective  Association,  and  that,  there- 
fore, such  a  woman's  police  bureau  is  not  needed,  our  answer  would  be: 

First — That  in  proportion  as  such  private  organization  has  shown  its 
necessity  to  the  police  and  courts,  in  that  same  proportion  has  it  proved 
such  service  to  be  a  legitimate  responsibility  of  government. 


426  Hospital  and  Health  Survey 

Second — That,  having  demonstrated  the  need,  and  blazed  the  trail,  such 
private  organization  should  insist  on  the  city  paying  its  own  way,  and  should 
assist  the  city  in  getting  such  a  bureau  well  organized,  and  see  to  it  that  it 
functions  in  accordance  with  the  best  and  most  approved  methods. 

Using  this  modern  conception  of  the  function  of  police  departments, 
that  they  aim  at  prevention  as  well  as  detection  of  crime,  it  is  suggested  that 
the  test  of  their  efficiency  lies  not  in  the  number  of  arrests  and  convictions  (the 
usual  form  of  report  made),  but  in  the  relation  which  such  number  of  arrests 
and  convictions  bears  to  the  whole  number  of  offenses  committed. 

This  test  is  easily  applied  to  crimes  which  become  public,  such  as  mur- 
der, burglary,  etc.,  or  even  to  all  minor  offenses  concerning  which  complaints 
are  filed. 

Even  as  to  such  offenses,  however,  the  reports  of  the  police  departments 
rarely  bring  out  the  deadly  parallel.  A  real  difficulty  confronts  us  when  we 
try  to  apply  the  test  to  sex  offenses. 

These  offenses  differ  from  offenses  against  the  person  or  property  in  the 
fact  that  the  danger  to  the  public,  while  more  serious,  is  less  apparent,  so 
that  the  public  rarely  and  the  individuals  most  directly  concerned  never 
file  complaints.  The  police  could  not,  therefore,  if  they  wished,  apply  this 
test  to  their  efficiency  in  preventing  and  detecting  sex  offenses. 

The  fact,  therefore,  that  the  Cleveland  police  department  has  not  issued 
a  report  for  six  years  is  of  less  importance  to  this  survey,  than  would  at  first 
seem  probable.  There  are  two  remedies  for  this  situation,  both  of  which 
have  proved  successful. 

1.  Educate  the  public  to  make  complaints. 

2.  Form  a  committee  of  citizens,  whose  duties  shall  include  vice  investiga- 
tion. 

The  citizens  of  one  large  camp  city,  during  the  war,  were  so  educated  to 
the  necessity  of  protecting  the  troops,  that  the  Vice  Squad  spent  its  entire 
time  investigating  complaints  filed  by  patriotic  citizens.  New  York,  Chicago, 
Minneapolis,  San  Francisco,  Los  Angeles  and  many  other  smaller  cities  have 
adopted  the  second  alternative  and  maintained  a  committee  with  investi- 
gators to  check  up  the  work  of  its  departments  and  to  take  the  place  of  the 
reluctant  public  in  filing  complaints.  The  second  alternative  is  believed  to  be 
the  best,  because  while  working  gradually  to  bring  about  the  first  (a  slow  and 
laborious  process  in  peace  times),  it  can  secure  immediate  results  from  the 
police  and  greatly  strengthen  and  coordinate  all  the  various  municipal  de- 
partments which  handle  this  problem. 

It  can  strengthen  these  departments  by  interpreting  them  to  the  public 
and  the  public  to  them.  It  can  also  help  them  to  get  needed  legislation, 
appropriations  and  the  right  kind  of  personnel. 

It  can  coordinate  them  by  helping  to  bring  about  team  work  in  govern- 
ment. In  our  government  system  of  checks  and  balances,  there  often  de- 
velops a  tendency  to  "pass  the  buck"  from  one  department  to  another. 


Venereal      Disease  427 

If  things  go  wrong  and  crime  increases,  the  police  and  the  courts  blame  each 
other  and  the  prosecuting  attorney,  while  the  latter  shifts  the  burden  to  the 
other  two.  An  intensive  comparative  study  of  records  and  methods,  by  an 
impartial  organization,  will  reveal  the  weak  links  in  the  chain.  Tactful  and 
constructive  criticism  given  privately  to  the  departments  at  fault  will  often 
serve  to  remedy  conditions.  Conferences  arranged  between  department 
heads  with  the  secretary  or  a  member  of  the  citizens  committee,  acting  as 
liason  officer,  may  remove  the  friction.  As  a  last  resort  the  public  can  be 
informed  and  the  pressure  of  public  opinion  applied. 

We  desire  to  make  two  recommendations  in  connection  with  court  ad- 
ministration. These  are  the  establishment  of  a  Woman's  Court  and  a  finger- 
print system  for  all  convicted  sex  delinquents.  The  essentials  of  a  woman's 
court  are  the  trial  of  all  women  sex  offenders  in  a  separate  court,  or  at  least 
at  a  separate  period  of  the  day,  by  one  judge,  and  the  exclusion  of  everyone 
from  the  trials  who  cannot  show  a  legitimate  interest  therein.  The  advan- 
tages of  such  procedure  are  the  development  of  expert  knowledge  by  the 
judge,  a  consistent  judicial  policy  and  an  immense  improvement  in  the 
dignity  and  efficiency  of  court  procedure. 

The  finger-print  system  for  convicted  sex  offenders  is  of  the  utmost  value 
to  the  judge  in  his  disposition  of  cases.  Repeaters  constantly  give  false 
names  and  often  escape  identification  without  such  a  system.  As  above 
indicated,  the  test  of  court  treatment  is  the  proportion  of  offenders  who 
repeat.  This  test  cannot  be  applied  without  an  infallible  system  of  identi- 
fication. The  finger-print  system  is  the  only  one  that  is  infallible.  Con- 
structively it  enables  the  judge  to  determine,  within  five  minutes  after  con- 
viction of  an  offender,  the  probable  value  of  probation,  reformatory  treat- 
ment and  the  need  for  mental  examination. 

Its  cost  would  for  Cleveland  probably  not  exceed  $2,500  for  the  first 
year,  and  less  thereafter.  Any  intelligent  policeman  can  be  taught  to  oper- 
ate it. 


VICE  CONDITIONS 

In  an  attempt  to  apply  the  test  of  efficiency  above  described  to  the  Cleve- 
land police  department,  an  under-cover  investigation  was  made  to  determine 
the  extent  to  which  the  laws  against  sex  offenses  were  being  violated  without 
fear  of  the  police. 

This  investigation  did  not  disclose  the  existence  of  a  red  light  district  or 
any  open  or  public  houses  of  prostitution.  Little  soliciting  was  observed 
on  the  streets,  and  the  dance  halls  were  not  apparently  being  used  for  this 
purpose. 

The  situation  at  many  of  the  hotels  was,  however,  found  to  be  inexcusably 
bad.  Prostitutes  in  many  of  these  were  permitted  to  operate  without  fear, 
and  in  some  of  them  employes  of  the  hotels  assisted  the  prostitutes  by  bring- 
ing customers  to  them  or  sending  them  to  the  rooms  of  customers. 


428  Hospital  and  Health  Survey 

Many  chauffeurs  and  taxicab  stands  readily  agreed  to  take  investigators 
to  prostitutes  and  a  few  restaurants  were  observed  to  permit  this  type  of 
women  to  frequent  their  dining  rooms. 

In  general  it  may  be  said  that  prostitutes  do  not  flaunt  themselves  in  the 
public  eye.  but  there  appears  to  be  a  large  amount  of  clandestine  prostitu- 
tion, which  easily  escapes  detection  or  restraint  by  the  police. 

Much  of  this  fearlessness  by  Cleveland's  prostitutes  has  probably  been 
due  in  the  past  to  the  Golden  Rule  method  of  treatment  which  turns  these 
women  back  on  the  streets  on  confession  of  their  offenses. 

None  of  the  city  departments  was  apparently  aware  of  the  existence  of 
the  new  state  law  against  prostitution  above  described,  as  late  as  November, 
1919,  some  five  months  after  its  passage. 

This  law  eliminates  fines  and  provides  for  long  sentences.  It  is  our 
understanding  that  sex  offenders  will  be  charged  under  this  law  exclusively 
hereafter,  and  the  golden  rule  system  abandoned.  Improvement  should 
result. 

The  police  have  ample  legal  weapons  for  breaking  up  automobile  traffic 
in  vice  under  the  new  prostitution  law.  This  law,  together  with  the  Injunc- 
tion and  Abatement  Law  and  the  law  giving  the  State  Fire  Marshal  power  to 
close  hotels  and  restaurants  which  permit  immoral  or  disorderly  conduct, 
provide  legal  tools  which  leave  the  city  authorities  no  excuse  for  the  condi- 
tions above  described. 


Venereal      Disease  429 


IV.       Protective  Social  Measures 

Recreation 

AS  a  large  part  of  venereal  disease  is  due  to  the  wrong  use  of  leisure 
time,  wholesome  recreation  for  its  right  use  is  a  measure  of  prime  im- 
portance in  any  venereal  disease  reduction  campaign.  The  public 
responsibility  in  this  regard  is  established.  Millions  of  dollars  are  being 
spent  by  official  and  unofficial  organizations  throughout  the  country  to  fill  this 
need.  Playgrounds,  parks,  public  school  athletic  leagues,  gymnasia,  swim- 
ming pools,  recreation  piers,  as  well  as  such  national  organizations  as  the 
Boy  Scouts,  Girl  Scouts,  Campfire  Girls,  and  others,  attest  the  general 
recognition  of  this  responsibility. 

In  spite  of  these  developments  in  which  Cleveland  shares  with  other  cities 
of  its  size  and  importance,  much  yet  remains  to  be  done  to  discharge  this 
community  responsibility.  The  exhaustive  recreation  survey  recently  com- 
pleted by  the  Cleveland  Foundation  renders  unnecessary  here  a  detailed 
analysis  of  the  needs  of  Cleveland,  and  the  recent  employment  of  a  director 
of  recreation  is  an  excellent  guarantee  that  the  city  accepts  the  responsibility. 
It  is  sufficient  for  our  purpose  to  state  the  relation  of  recreation  to  the  venereal 
disease  problem  and  its  importance  as  a  measure  for  prevention   of  disease. 

Prevention  Work  for  Women  and  Girls 

Pending  the  development  of  an  adequate  recreation  program,  and  indeed 
supplementary  thereto,  is  the  responsibility  for  the  protection  of  those  indi- 
viduals who  do  not  or  cannot  avail  themselves  of  these  opportunities  for  the 
right  use  of  leisure  time.  Protection  also  is  needed  for  individuals  who  have 
failed  to  adjust  themselves  to  their  environment  and  are  guilty  of  some  infrac- 
tion of  the  law  through  ignorance  or  heedlessness,  in  order  to  prevent  them 
from  becoming  habitual  delinquents.  A  further  type  of  protection  involves  the 
supervision  of  commercialized  amusements,  such  as  theaters,  dance  halls, 
restaurants,  cabarets,  public  parks,  beaches,  road  houses,  etc.  The  most 
recent  development  in  administrative  machinery  affording  such  protection 
is  the  Woman's  Police  Bureau.  In  Cleveland,  as  in  other  cities,  this  respon- 
sibility has  been  assumed  largely  by  the  unofficial  Women's  Protective  Asso- 
ciation. In  Washington  and  other  cities  this  work  has  been  accomplished 
by  the  Women's  Police  Bureau  attached  to  the  Police  Department.  Rightly 
organized  and  with  adequate  personnel  it  is  believed  that  the  Police  Bureau 
offers  the  best  machinery  for  providing  this  protection. 

The  guidance  and  supervision  of  sex  delinquents  who  are  not  yet  hardened 
offenders,  through  probation,  has  demonstrated  its  value  in  the  prevention 
of  much  social  wreckage,  with  its  resulting  venereal  disease.  Wise,  kindly, 
and  humane  probation  officers  can  and  do  adjust  economic  and  domestic 
difficulties  and  are  agents  of  recognized  value  in  preventive  medicine. 


430  Hospital  and  Health  Survey 

Institutional  Care  of  Sex  Delinquents 

Where  the  mentality  of  a  sex  delinquent  is  weak  or  the  environment  has 
been  such  that  the  delinquent  will  not  be  benefited  by  probation,  the  com- 
munity as  well  as  the  individual  must  be  protected  by  institutional  care. 
Colonies  for  the  feeble-minded,  reformatories,  etc.,  for  those  for  whom 
rehabilitation  is  possible,  have  been  approved  by  the  most  advanced  thought 
of  students  in  this  field. 


Venereal     Disease  431 

V.      Sex  Education 

ANY  program  for  the  eradication  of  hunian-contact  diseases,  such  as 
tuberculosis,  syphilis  and  gonococcus  infections,  which  are  so  diffi- 
cult of  prompt  recognition,  so  insidious  in  their  onset  and  methods  of 
transmission,  and  so  successful  in  their  development  of  carriers,  must  in- 
clude education  as  one  of  its  outstanding  features.  Such  education  naturally 
divides  itself  into,  first,  the  training  of  those  not  yet  infected  in  the  applica- 
tion of  measures  for  their  protection,  and,  second,  the  instruction  of  those 
who  are  already  infected  in  the  value  of  persistent  and  curative  treatment 
and  in  measures  for  the  avoidance  of  infection  of  others.  The  latter  in- 
struction must  necessarily  be  carried  out  by  doctors,  nurses,  public  health 
officials  and  others  who  are  dealing  with  infected  persons.  For  practical 
purposes,  therefore,  educational  measures  must  be  directed  toward  the  great 
mass  of  the  population  who  are  not  infected,  and  may  be  grouped  under  four 
headings : 

Sex  education  for  children. 

Sex  instruction  for  young  men  and  women. 

Social  hygiene  information  for  parents  and  leaders  of  public  opinion. 

Permanent  sex  education  measures. 

Sex  Education  for  Children 

It  is  just  as  reasonable  and  practicable  for  the  health  officer  to  plan  twenty 
years  into  the  future  a  campaign  of  protection  of  the  public  from  a  given 
disease,  as  it  is  to  plan  ten  thousand  miles  in  distance.  In  the  latter  case 
the  federal  public  health  authorities  expect  and  receive  the  support  of  the 
public  in  placing  health  officers  in  India,  China  and  other  distant  lands,  in 
order  to  prevent  bubonic  plague  from  reaching  the  seaports  of  the  United 
States  and  becoming  an  imminent  danger.  In  the  former  case  it  is  reason- 
able for  the  health  officer  to  expect  full  cooperation  and  support  of  the 
public  in  placing  proper  officers,  so  to  speak,  twenty  years  in  the  future  to 
establish  barriers  for  the  prevention  of  exposure  of  citizens  of  the  United 
States  to  syphilis  and  gonococcus  infections.  This  is  only  another  way  of 
stating,  of  course,  that  the  barriers  which  will  prove  most  effective  in  pro- 
tecting against  these  diseases  are  proper  sex  education,  right  methods  of 
thought,  religious  and  ethical  training,  and  adequate  environmental  protec- 
tion against  exposure.  For  such  educational  and  environmental  measures 
to  have  their  largest  influence,  work  must  be  begun  in  early  childhood  and 
be  continued  until  the  individuals  concerned  are  fully  established  in  their 
homes  as  adult  citizens.  The  task  of  promoting  this  phase  of  preventive 
measures  must  eventually  necessarily  fall  to  the  trained  educators,  although 
all  public  health  officials  can  be  of  very  great  assistance. 

While  the  purposes  of  this  report  do  not  permit  of  full  discussion  of  sex 
education,  it  is,  perhaps,  permissible  to  point  out  that  the  consensus  of 
opinion  of  educational  and  public  health  authorities  favors  a  sex  education 
program  based  on  the  fundamental  proposition,  that  social  hygiene  education 


43-2  Hospital  and  Health  Survey 


in  schools  and  colleges  should  not  be  given  prominence  as  a  so-called  course 
or  courses  of  sex  instruction  by  a  special  individual  or  teacher,  but  rather, 
that  all  teaching  concerning  sex  and  its  manifold  relations  to  human  life 
should  be  merged  unobtrusively  into  regular  subjects  of  training  and  instruc- 
tion, notably  the  biological  sciences,  general  hygiene,  nursing,  physical  edu- 
cation, social  ethics,  literature,  home  making,  practical  training  for  an 
occupation  or  profession. 

Sex  Instruction  of  Young  Men  and  Women. 

Annually  a  very  large  number  of  young  men  and  women  emerge  from  the 
state  of  protected  childhood  to  the  responsibilities  of  maturity  and  adult 
life.  The  age  at  which  this  transition  occurs  for  different  groups  varies 
according  to  the  home  conditions,  industrial  demands  and  environmental 
and  educational  influences  for  each  group.  The  transition  having  occurred 
prior  to  successful  sex  education  work  and  training,  there  remains  the  oppor- 
tunity to  give  these  young  people  sound  instruction  in  matters  of  wholesome 
sex  relations  and  the  methods  of  transmission  and  prevention  of  the  venereal 
diseases.  For  the  most  part,  since  young  people  at  this  age  are  no  longer  in 
school,  the  dissemination  of  such  knowledge  must  be  through  continuation 
school  courses,  instruction  of  the  membership  of  religious,  fraternal  and  other 
social  organizations,  and  the  voluntary  efforts  of  social  hygiene  agencies, 
working  in  cooperation  with  the  health  education  authorities. 

Socl\l  Hygiene  Information   for   Parents  and  Leaders 
of  Public  Opinion. 

In  promoting  this,  as  in  all  other  public  health  programs,  it  is  essential 
to  have  the  support  of  public  opinion.  And  since  syphilis  and  gonococcus 
infections  are  spread  by  human  carriers  through  methods  which  may  best  be 
combated  by  simple  measures  of  control  which  lie  within  the  power  of  the 
individual  not  yet  infected,  even  though  he  does  not  know  the  identity  of 
the  infected  persons,  the  active  cooperation  of  parents  in  beginning  the  edu- 
cation and  training  of  their  children  toward  the  ultimate  application  of  these 
methods  is  of  paramount  importance.  For  these  reasons  it  is  necessary  to 
promote  in  every  practicable  way  the  extension  of  social  hygiene  information 
to  parents  and  leaders  of  public  opinion.  Among  the  successful  plans  which 
have  been  tried  in  this  connection  are  parent  teacher  meetings,  popular 
addresses  to  industrial  groups,  luncheon  discussions  under  the  auspices  of 
commercial  business  and  social  organizations,  clubs  of  men  and  women, 
appropriate  distribution  of  selected  pamphlets,  motion  picture  and  exhibit 
presentation  of  the  venereal  disease  problem  and  its  solution. 

Permanent  Sex  Education  Measures. 

By  way  of  illustration,  various  temporary  expedients  in  promoting  educa- 
tion have  been  indicated  under  "a,"  "b"  and  "c,"  but  it  should  be  borne  in 
mind  that  ultimately  as  time,  adequate  methods  and  personnel  become 
available,  the  essentials  of  needed  sex  education  should  find  their  way  through 
the  normal  channels  of  popular  education  and  religious  and  social  training. 
As  a  rule  permanent  advances  in  any  field  of  social  betterment  result  from 


Venereal      Disease  433 

activities  which  pass  through  three  stages:  first,  the  assembling  and  testing 
of  data  and  proposal  of  practical  measures;  second,  active  propaganda  for 
the  adoption  of  the  proposed  measures  in  the  course  of  which  the  subject 
comes  to  popular  attention  with  an  apparently  exaggerated  view  of  its  im- 
portance in  relation  to  the  whole  of  life  and  social  progress;  third,  the  quiet, 
general  application  of  the  permanent  measures  public  opinion  endorses,  and 
education  of  each  succeeding  generation  as  to  the  need  for  continuing  such 
measures.  The  latter  task  always  falls  to  the  constituted  educational 
authorities  with  the  cooperation  of  parents  and  the  powerful  influence  of 
convention  and  custom.  Success  may  be  hoped  for  in  the  elimination  of 
venereal  disease  only  in  so  far  as  such  broad  principles  of  education  are 
applied. 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

X.     Hospitals  and  Dispensaries. 

XI.     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 

The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 

THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Mental  Diseases 
and  Mental  Deficiency 


Part  Six 


Cleveland    Hospital    and 
Health    Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 

308  Anisfield  Bldg. 
Cleveland    -  Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators : 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the*,Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  oT  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

I.    Introduction  Page 

Mental  Factors  in  Medical  and  Social  Problems 443 

Complaints  of  the  Community 444 

II.    City  Facilities  for  Diagnosis  and  Treatment 

Cleveland  City  Hospital 446 

Provisions  for  Mental  Patients  in  Other  General  Hospitals 

Lakeside  Hospital _ 460 

Fairview  Park  Hospital 461 

Mt.  Sinai  Hospital. 461 

Lakewood  Hospital 461 

Other  General  Hospitals .. 461 

Dispensaries __ '. 462 

Private  Sanitaria  for  Mental  Patients... 462 

Places  Other  Than  Hospitals  for  Detention  or  Care 

County  Jail 464 

City  Infirmary 465 

III.  State  Facilities  for  Diagnosis  and  Treatment 

State  Board  of  Administration 467 

Laws  Relating  to  Insane,  Mentally  Defective  and  Epileptic 468 

State  Hospitals  for  Mental  Diseases 469 

State  Institution  for  Feeble-minded 471 

State  Hospital  for  Epileptics : 473 

Bureau  of  Juvenile  Research . 473 

IV.  Courts  and  Correctional  Agencies 

Courts 

Probate  Court _ 476 

Municipal  Court 478 

Parole  Board I 479 

Juvenile  Court  and  Detention  Home 480 

Correctional  Agencies 

House  of  Correction _ 482 

Farm  School 484 

Girls'  Home _ 484 

House  of  Good  Shepherd , 485 

Boys'  School 1 , _ 486 

Other  Homes _ 487 

V.   Mentally  Atypical  Children 

Special  Classes  for  the  Mentally  Defective 488 

Work  Permits  for  the  Mentally  Defective 490 

Special  Types  of  Atypical  Children _ _ 494 

After-care  and  Supervision 1„  495 

VI.  Welfare  Organizations 497 

VII.  Prevention — Mental  Hygiene 501 

VIII.  Summary  of  Recommendations 

Dealing  with  State  Legislation  and  Local  Ordinances  or  Charter  Changes 503 

Dealing  with  Departments  of  State  and  City  Government..... 505 

Dealing  with  Private  Agencies  by  Groups 508 

Dealing  with  New  Agencies  or  Private  Facilities  to  be  Established, 509 


PREFACE 

THE  National  Committee  for  Mental  Hygiene  was  requested  by  the 
Director  of  the  Cleveland  Hospital  and  Health  Survey  to  make  a  study 
of  the  provisions  for  dealing  with  the  medical  and  social  problems  aris- 
ing out  of  mental  disease  and  mental  deficiency,  as  it  was  felt  that  the  field 
to  be  covered  was  such  a  special  one  that  an  organization  with  experience 
in  conducting  such  studies  would  be  most  apt  to  obtain  a  clear  picture  of 
existing  conditions  and  to  make  sound  recommendations.  Those  in  charge 
of  the  general  Survey  have  made  me  feel  at  all  times  that  my  share  in  the 
work  constituted  an  integral  part  of  the  larger  undertaking,  and  I  wish  to 
express  my  deep  appreciation  not  only  of  their  cooperation  but  of  the  sym- 
pathetic understanding  with  which  my  work  in  a  special  field  has  been  re- 
garded. 

It  is  difficult  to  render  proper  acknowledgment  to  individuals  for  assist- 
ance and  advise  when  all  of  those  with  whom  I  came  in  contact  during  the 
Survey  gave  me  every  possible  assistance.  Nevertheless,  the  following  per- 
sons contributed  of  their  time  and  wise  counsel  so  liberally  that  special 
acknowledgment  should  be  made: 

Hon.  Howell  Wright,  who  supplied  information,  advice,  and  secured 
data  otherwise  difficult  to  obtain;  Hon.  Alexander  Hadden,  Judge  of  the 
Probate  Court;  Hon.  George  S.  Addams,  Judge  of  the  Juvenile  Court;  Hon. 
Dudley  S.  Blossom,  Director  of  Public  Welfare;  Dr.  Chas.  W.  Stone;  Dr. 
Leonard  R.  Ravitz,  who  assisted  in  the  neuro-psychiatric  examinations; 
H.  Austin  Aikins,  Ph.  D.,  Professor  of  Psychology,  College  for  Women, 
Western  Reserve  University,  who  made  the  psychological  tests;  Miss  Claire 
Walters,  who  assisted  actively  with  personal  work,  information  and  in  secur- 
ing documents;  Miss  Cecelia  A.  Evans,  of  the  Public  Health  Nursing  Course 
at  Western  Reserve  University,  who  took  much  interest  and  enabled  three 
of  the  pupils,  Miss  Nesbit,  Miss  Graham  and  Mrs.  King,  to  render  valuable 
direct  assistance  in  the  work;  Miss  Charlotte  Steinbach,  Supervisor  of  Spe- 
cial Classes  in  the  public  schools. 

The  various  welfare  organizations,  especially  the  Associated  Charities 
who  cooperated  in  making  a  study  of  their  families,  and  the  Welfare  Federa- 
tion and  the  Humane  Society  who  arranged  for  and  assisted  in  the  examina- 
tion of  inmates  of  orphanages  and  other  institutions  and  of  children  boarded 
out  in  families. 
The  methods  by  which  my  studies  were  carried  on  are  of  little  general 
interest  and  so  I  will  not  describe  them  in  detail.     Every  institution  in 
which  the  problems  of  mental  disease  and  mental  deficiency  seemed  likely 
to  be  encountered  was  visited,  in   many   cases   a   number  of  times.     Five 
hundred  and  forty-one  individuals  in  various  hospitals,  homes,  clinics  and 
schools  were  carefully  examined  by  psychiatrists  and  psychologists   with  a 
view  to  determining  their  mental   condition   and  the  type  of  treatment  or 
supervision  that  they  actually  required.       A  large  number  of  people  whose 
work  dealt  even  slightly  with  these  problems,   were  consulted  personally 
or  through  correspondence,  and  official  reports  and  other  publications  were 
freely  used.     It  is  impossible  to  assign  proper  credit  where  extracts  have 
been  made  from  so  many  different  publications,  so  I  take  the  opportunity 
here  of  making  a  general  acknowledgment. 

Jesse  M.  W.  Scott, 

Field  Consultant, 
National  Committee  for  Mental  Hygiene 


Mental  Diseases  and  Mental  Deficiency 

by 

Thomas  W.  Salmon,  M.  D. 

Director  of  Mental  Hygiene  Survey 

and 

Jesse  M.  W.  Scott,  M.  D. 

Field  Consultant 

National  Committee  for  Mental  Hygiene 

Introduction 

NOT  long  ago  mental  diseases  and  mental  deficiency  were  thought  to 
present  only  one  group  of  problems,  that  dealing  with  the  proper 
institutional  care  of  persons  who  suffer  from  these  disorders.  Slowly, 
as  medical  and  social  work  in  relief  and  rehabilitation  became  more  ex- 
tensive in  scope  and  intensive  in  method,  it  became  apparent  to  those  en- 
gaged in  such  work  that  mental  factors,  at  one  time  in  one  form  and  again 
in  another,  complicate,  or,  in  many  cases,  entirely  condition  the  individual 
or  social  situations  which  require  attention.  No  American  cities  attempt 
now  to  deal  with  the  great  social  problems  arising  out  of  disorders  of  con- 
duct of  their*  citizens  by  measures  applicable  only  to  groups  of  persons. 
We  know  that  behind  social  mal-adaptation  lies  the  mal-adaptation  of  some 
individual  or  individuals,  and  that  behind  the  mal-adaptations  of  individuals 
lie  those  mental  factors  which  determine  behavior.  Sometimes  such  factors 
produce  conditions  which  are  generally  recognized  as  mental  disease  or 
states  of  defective  mental  development.  Sometimes  they  produce  altera- 
tions in  behavior  which  do  not  follow  conveniently  the  conventional  boun- 
daries of  mental  disease  or  mental  defect.  It  is  very  widely  recognized, 
however,  that  the  success  of  efforts  for  the  economic  or  social  reconstruction 
of  individuals  or  families  who  become  liabilities  to  their  community  instead 
of  remaining  assets,  depends  largely  upon  the  personal  resources  of  the 
individuals  concerned,  and  that  among  these  resources  none  compares  in 
its  actual  influence  upon  life  with  their  type  of  mental  reactions.  With  a 
normally  adaptable  mind,  severe  physical  and  economic  handicaps  are 
overcome,  but  with  a  mind  defective  from  birth  or  damaged  by  disease, 
ordinary  tasks  in  personal  or  social  adaptation  are  difficult  or  impossible. 

Mental  Factors  in  Medical  and  Social  Problems 

It  is  one  thing  to  recognize  the  importance  of  mental  factors  in  the  social 
and  medical  problems  of  a  community  and  another  to  devise  methods  by 
which  the  community  can  best  deal  with  these  factors.  There  is  general 
lack  of  exchange  of  ideas  on  this  subject  between  American  cities.  Experi- 
ments that  have  failed  in  one  place,  through  intrinsic  causes  of  failure,  are 
embarked  upon  hopefully  in  another.  In  no  city  is  all  the  work  of  the 
community  that  deals  with  mental  disease  and  mental  deficiency  centered  in 
a  single  administrative  department.  In  general,  the  task  of  unofficial  wel- 
fare agencies  is  to  make  beginnings  before  the  official  authorities  are  ready 
or  free  to  act,  and  to  deal  informally  with  individuals  who  are  in  difficulties 
before  the  graver  situations  with  which  the  official  agencies  are  especially 


444  Hospital  and  Health  Survey 


prepared  to  cope  have  arisen.  Often,  unfortunately,  there  is  lack  of  con- 
tinuity between  the  activities  of  official  and  unofficial  agencies.  In  con- 
sequence, one  sees  the  most  perplexing  and  wasteful  duplication  of  effort. 
Water  is  poured  liberally  on  the  smoke  while  the  fire  often  burns  unchecked. 


It  has  been  the  purpose  of  this  Survey  not  only  to  trace  as  closely  as 
possible  the  tangled  relationships  which  mental  disease  and  mental  deficiency 
bear  to  other  problems  and  to  examine  and  appraise  the  value  of  the  dif- 
erent  efforts,  large  and  small,  official  and  unofficial,  which  the  city  is  putting 
forth  in  its  effort  to  deal  with  them;  as  so  much  of  real  governmental  re- 
sponsibilities are  taken  over,  for  the  time  being  at  least  in  this  country,  by 
voluntary  welfare  agencies,  the  Survey  has  dealt  quite  as  fully  with  the  work 
of  the  latter  as  with  that  of  the  city  itself.  It  is  felt  that  the  presentation 
in  full  of  the  very  large  amount  of  detailed  information  collected  would  serve 
no  useful  purpose,  and  so  only  an  outline  of  actual  findings  is  given,  the  space 
available  in  this  report  being  devoted  chiefly  to  a  consideration  of  the  means 
by  which  the  city  can  best  deal  in  a  constructive  and  progressive  way  with 
the  problems  that  are  indicated. 


Complaints  of  the  Community 

In  medicine,  no  intelligent  physician  undertakes  to  examine  a  patient  or 
to  recommend  treatment  until  he  has  heard  a  spontaneous  account  by  the 
patient  himself  of  the  complaints  which  led  him  to  seek  assistance.  It 
seems  proper,  therefore,  to  commence  this  Survey  with  a  brief  statement  of 
the  complaints  that  the  community  has  to  make  in  relation  to  the  provisions 
existing  in  Cleveland  for  the  diagnosis,  treatment  and  supervision  of  persons 
with  mental  diseases  or  mental  deficiency. 

Physicians  complain  that  no  adequate  provisions  are  made  by  the  city 
for  the  temporary  observation  of  persons  with  mental  diseases  during  the 
period  in  which  measures  for  their  future  are  being  considered,  nor  for  their 
emergency  treatment.  They  say  that  the  rich  or  well-to-do  find  the  facilities 
they  need  in  private  institutions,  but  for  the  poor  and  those  in  moderate 
circumstances,  upon  whom  the  stress  of  disease  falls  so  heavily,  the  city 
offers  nothing  more  than  a  partly  custodial  and  partly  correctional  type  of 
institution  connected  with  the  City  Hospital,  in  which  the  modern  treatment 
of  mental  disorders  has  no  place.  They  complain  also  that  the  state  of  Ohio 
has  made  so  much  less  provision  for  the  continued  care  of  mental  cases  than 
the  population  requires,  that  Cleveland,  in  addition  to  performing  the  emer- 
gency services  mentioned  above,  must  also  provide  continued  care  for  many 
persons  simply  on  account  of  the  failure  of  the  state  to  perform  its  well- 
recognized  share  of  the  duty.  They  assert  that  such  conditions  make  per- 
sons with  mental  diseases  reluctant  to  apply  for  treatment  in  the  earlier 
stages  of  their  disorders,  in  which  effective  measures  of  treatment  are  most 
likely  to  prove  successful.  Far  from  extending  aid  to  those  suffering  from 
mental  disorders,  the  absence  of  proper  facilities  and  the  harsh  legal  methods 
so  generally  employed  serve,  they  say,  most  effectively  to  cause  mental 
patients  to  conceal  their  troubles.  They  complain  that  the  law  plays  a  much 
larger  part  than  medicine  in  the  management  of  mental  diseases  in  Cleveland, 


Mental  Diseases  and  Deficiency  445 

and  that  legal  measures  properly  applicable  to  a  very  small  proportion  of 
mental  patients  are  applied  to  practically  all,  with  the  result  that  much  avoid- 
able suffering  and  humiliation  accompanies  illnesses  painful  enough  to  the 
patients  and  their  relatives  without  such  additional  inflictions. 

Welfare  agencies  which  have  to  deal  with  that  part  of  the  city's  problem 
of  caring  for  the  mentally  ill  that  has  been  mentioned  and,  in  addition,  with 
many  trying  social  situations  which  grow  directly  or  indirectly  out  of  mental 
disorders,  complain  that  there  are  many  insane  and  feeble-minded  persons 
in  institutions  not  intended  for  them  and  in  families  in  the  community,  and 
that  the  presence  of  those  who  are  for  purely  humanitarian  reasons  sheltered 
in  institutions  designed  for  another  purpose  prevents  such  institutions  from 
successfully  carrying  out  their  original  purposes,  and  is  of  little  or  no  benefit 
to  the  mentally  defective  who  are  received.  These  agencies  complain  that 
no  psychiatric  or  psychological  examinations  are  made  when  dependents 
are  received  into  orphanages  and  other  welfare  institutions  or  sent  to  homes 
to  be  boarded  out.  They  say  that,  in  the  absence  of  facilities  for  psychiatric 
diagnosis  in  well-staffed,  well-equipped  psychiatric  clinics,  they  have  to  make 
shifts  for  themselves  which  are  not  only  ineffective  but  often  wasteful  of 
time  and  money.  They  feel  that  some  of  their  most  difficult  and  apparently 
hopeless  problems  could  be  solved  if  the  state  bore  the  share  of  the  burden 
of  institutional  care  that  is  borne  by  most  other  states. 

The  judges  complain  that  the  task  assigned  to  them  by  the  archaic  laws 
of  Ohio  governing  the  legal  management  of  mental  diseases,  is  a  burden- 
some one  and  that  not  infrequently  they  are  compelled  to  do  grave  injustice 
to  sick  persons  because  of  the  lack  of  an  adequate  mechanism  for  determin- 
ing the  questions  at  issue. 

It  has  been  our  task  to  examine  the  foundations  for  these  grave  com- 
plaints and  to  suggest  remedies  that  have  been  effective  when  applied  else- 
where. 


446  Hospital  and  Health  Survey 


City  Facilities  for  Diagnosis  and  Treatment 

WHAT  basis  is  there  for  the  complaint  by  physicians  that  Cleveland 
is  without  facilities  even  for  the  emergency  care  and  observation  of 
mental  cases,  because,  for  this  type  of  illness,  the  public  and  private 
hospitals  of  the  city  have  practically  nothing  to  offer?  It  is  convenient 
to  consider  first  the  great  City  Hospital — the  chief  resource  of  the  sick 
poor — and  then  the  other  hospitals  which  can  be  looked  to  to  supplement 
ihe  work  of  this  institution. 

Cleveland  City  Hospital 

The  general  features  of  Cleveland  City  Hospital  have  been  very  fully 
described  in  other  sections  of  this  report. 

This  hospital  is  far  from  being  adequate.  As  the  report  in  Part  X.  indi- 
cates, the  buildings  are  old,  equipment  is  largely  out-of-date,  and  many 
facilities  possessed  by  a  hospital  completely  equipped  to  discharge  its  obli- 
gations to  the  sick  of  the  community  are  lacking.  Nevertheless,  scientific 
medicine  and  surgery  find  their  way  into  every  general  ward  to  the  ex  cent 
of  the  facilities  available.  When  a  new  patient  is  admitted  every  effort  is 
made  to  discover  the  nature  of  the  disease  from  which  he  suffers  and  the 
possibility  of  bringing  about  his  speedy  recovery,  amelioration  of  his  con- 
dition or  relief  from  his  distress.  Let  a  medical  or  surgical  discovery  in 
therapeutics  be  made  in  any  great  medical  center  of  the  world  and  it  is  only 
a  little  while  before  it  is  applied  to  the  benefit  of  patients  in  this  hospital. 
Forming  as  it  does  a  part  of  the  clinical  resources  available  for  teaching  in 
the  medical  school  of  Western  Reserve  University,  cases  are  studied  not 
only  with  reference  to  their  own  needs,  but  to  the  means  by  which  their 
diseases  and  the  causes  of  these  diseases  can  best  be  presented  to  medical 
students  who  will  be  required  to  treat  similar  conditions  in  their  own  practice 
later  on. 

All  this,  however,  refers  only  to  the  general  ivards  of  the  City  Hospital. 
When  one  leaves  these  wards,  crosses  a  little  strip  of  grass  and  enters  the 
doors  of  the  building  devoted  to  mental  cases  he  leaves  behind  him  not  only 
the  medical  science  of  the  present  century,  but,  in  a  large  part,  its  humani- 
tarian attitude  towards  disease  and  suffering.  The  building  in  which  the 
wards  for  mental  patients  are  located  was  erected  in  1851  and  used  as  the 
city  poorhouse.  In  its  arrangement  you  will  see  no  evidence  of  thoughtful 
hospital  planning  to  meet  a  special  need  nor  even  bright  sunny  wards  such 
as  those  to  be  seen  in  other  portions  of  the  hospital.  A  wide,  dark  corridor 
runs  down  the  middle  of  each  floor,  with  little  cell-like  rooms  on  either  side. 
At  about  the  middle  this  central  corridor  is  crossed  by  another,  one  arm  of 
which  serves  as  a  dining  room  and  the  other  as  a  crowded  day  room.  The 
arm  of  the  transverse  corridor  used  for  a  day  room  has  a  bare  table  and  not 
enough  chairs  or  stools  for  the  patients  to  be  seated.  Along  the  central 
portion  are  cots  for  the  overflow.  The  place  would  be  depressing  enough, 
with  this  dark  corridor  and  the  cell-like  rooms,  but  the  discolored  and  dilap- 
idated walls  increase  its  gloomy  appearance.  The  rooms  are  about  eight  by 
nine  feet  in  size.  Although  they  provide  the  minimum  of  floor  space  allotted 
to  one  person,  many  of  them  are  occupied  by  two  patients.     Their  windows  are 


Mental  Diseases  and  Deficiency  447 

barred;  they  have  no  provision  whatever  for  artificial  illumination  and  for 
heat  they  depend  upon  radiation  from  the  corridors.  The  wooden  floors  are 
worn  nearly  through  and  it  is  impossible  to  keep  them  in  a  clean  and  sani- 
tary condition.  A  short  time  ago  a  woman  pulled  up  a  part  of  the  floor  in 
one  of  the  rooms  and  escaped  through  the  hole  which  she  had  made.  Rats 
and  bedbugs  are  numerous.  Each  floor,  which  accommodates  60  patients, 
has  but  a  single  bathtub  and  one  toilet  in  a  dilapidated  room.  There  are 
no  arrangements  for  the  use  of  hydrotherapy  nor  for  prolonged  tepid  baths. 
The  building  is  lighted  by  gas,  in  spite  of  the  dangers  in  this  kind  of  illumina- 
tion to  hospitals  for  mental  cases.  There  are  no  outside  porches,  but  a  small 
area  of  the  ground  is  enclosed.  Women  occupy  this  part  of  the  day,  and  men 
the  other,  except  in  bad  weather,  when,  for  weeks  at  a  time,  no  one  is  out. 

There  is  no  classification  of  patients.  The  anxious  and  depressed  and 
the  excited  and  noisy  occupy  the  same  ward.  Childhood  and  old  age  mingle. 
Social  distinctions  are  left  outside.  The  hard-working,  self-respecting 
mother  who  has  reared  her  children  in  a  clean  American  home  and  has  in 
her  later  years  developed  certain  mental  changes  listens  all  day  to  the  curses 
of  a  young  prostitute  in  a  bed  adjoining  hers. 

For  the  care  of  those  120  persons  suffering  from  serious  and  complex 
diseases,  nearly  every  one  of  whom  presents  an  individual  problem  in  diag- 
nosis or  treatment,  there  are  but  two  trained  nurses;  one  for  each  floor. 
For  the  rest,  dependence  is  placed  upon  untrained  women  attendants  for  the 
female  patients,  and  male  attendants  for  the  male  patients.  Mechanical 
restraint  is  used  freely.  In  the  absence  of  any  other  provision  dealing  with 
disturbed  conduct,  it  constitutes  a  relatively  humane  method.  The  one 
bright  spot  about  these  miserable  wards  is  the  kindly  spirit  which  is  shown 
by  attendants  toward  those  whom  misfortune  has  brought  into  their  care. 
Although  those  who  govern  this  great,  rich  city  have  failed  to  recognize  the 
needs  of  the  most  unfortunate  of  all  its  citizens,  the  poorly-paid  and  poorly- 
trained  people  who  spend  their  days  in  these  wards  try  to  make  up  by  their 
own  devotion  for  the  city's  neglect. 

The  "laboratory"  of  this  department  is  in  keeping  with  its  inadequacy 
in  all  other  respects.  It  is  a  single  room  where  analysis  of  urine  can  be 
made,  but  with  provision  for  practically  nothing  else.  There  is  no  diag- 
nostic or  therapeutic  equipment,  whatever,  not  even  an  apparatus  for  test- 
ing blood  pressure.  Simply  for  convenience,  a  certain  number  of  convales- 
cent cases  and  a  few  organic  nervous  cases  are  cared  for  in  this  department. 

This  place  has  been  visited  by  many  medical  visitors  familiar  with  the 
provisions  for  acute  mental  diseases  in  other  large  cities  in  the  United  States, 
and  they  are  agreed  that  none  maintains  a  poorer,  shabbier,  more  barren 
place  than  this.  It  is  a  place  of  custody  and  safe-keeping  to  which  no  term 
suggesting  a  hospital  is  applicable.  It  represents,  however,  the  exact  measure 
of  the  sympathy,  kindness  and  helpfulness  which  the  city  of  Cleveland  extends 
to  its  insane  poor.  Nothing  could  be  better  calculated  to  deter  those  seek- 
ing treatment  during  the  earliest  and  most  curable  stage  of  the  disease. 
Nothing  could  give  medical  students  and  pupil  nurses  a  more  distorted  con- 
ception of  the  needs  of  the  mentally  sick  and  of  the  resources  which  modern 


&q 


ss 


448 


450 


i*3 


=: 


451 


Wards  for  Mental  Patients,  Cleveland  City  Hospital — General  Bath  and  Toilet  for  Men. 


452 


A  Modern  Mental  Hospital — Baths  for  Treatment. 


453 


Wards  for  Mental  Patients,  Cleveland  City  Hospital — One  of  the  Cell-rooms 


454 


A  Modern  Mental  Hospital — Single  Room  for  Disturbed  Patient. 


455 


Wards  for  Mental  Patients,  Cleveland  City  Hospital — Excitement  controlled  by 
isolation  in  "Strong  Rooms." 


456 


A  Modern  Mental  Hospital — Excitement  controlled  by  prolonged  baths  and  skilled  nurse. 


457 


458  Hospital  and  Health  Survey 


science  and  humanity,  under  happier  conditions,  is  able  to  bring  to  bear 
upon  their  illness.  Nothing  could  affect  more  adversely  a  person  suffering 
from  a  depressed  form  of  mental  disease,  in  which  foreboding  and  fear  have 
taken  the  place  of  the  normal  mental  attitude,  than  to  be  brought  into  these 
wards,  every  feature  of  which  suggests  neglect  and  hopelessness.  Time  and 
indifference  have  painted  the  scenes  so  vividly  shown  in  the  accompanying 
photographs,  but  had  a  skillful  "movie"  director  desired  to  create  a  setting 
symbolic  of  poverty  and  despair  he  could  have  done  no  better. 

Fortunately,  this  deplorable  place  will  soon  be  a  thing  of  the  past.  The 
approval  of  the  bond  issue  for  a  new  City  Hospital  makes  it  possible  to  tear 
down  these  dilapidated  wards  and  replace  them  by  a  building  that  will 
reflect  the  modern  attitude  toward  mental  illness.  It  is  proposed  to  provide 
from  128  to  200  beds  in  the  new  City  Hospital  for  the  observation  and  tem- 
porary treatment  of  mental  cases.  If  these  provisions  are  wisely  planned 
so  as  to  provide  the  facilities  for  classification  and  special  care  which  are 
required  for  the  modern  treatment  of  acute  mental  disorders,  the  neglect  of 
the  last  half  century  may  be  atoned  for.  It  is  extremely  important  that  the 
plans  for  the  new  psychopathic  building  should  be  prepared  in  consultation 
with  those  who  are  familiar  with  such  departments  elsewhere  and  who  know 
the  precise  purposes  which  they  must  be  designed  to  serve.  Not  only  are 
new  buildings  needed,  however,  but  the  city  must  be  prepared  to  provide 
the  personnel  of  physicians,  nurses  and  attendants  needed  to  carry  on  treat- 
ment in  accordance  with  modern  standards.  An  adequate  ambulance 
service  is  essential  in  order  that  mental  cases  may  be  brought  there  from 
homes  under  the  same  conditions  as  those  by  which  other  sick  persons  com- 
ing under  treatment  are  received.  A  full-time,  resident  psychiatrist,  and 
at  least  two  assistants,  with  a  sufficient  number  of  internes,  will  be  needed. 
It  will  also  be  necessary  to  have  an  assistant  superintendent  of  nurses  who  will 
not  only  have  charge  of  the  nurses  and  pupil-nurses  attached  to  the  psycho- 
pathic department  but  will  direct  their  training  in  the  practice  of  mental 
nursing.  Occupation  instructors  will  be  needed  to  institute,  at  the  bedside 
and  in  the  workrooms,  occupational  treatment  especially  designed  to  meet 
the  needs  of  individual  cases. 

When  such  provisions  exist,  the  Probate  Court  will  no  longer  be  the  only 
course  of  admission.  Patients  will  be  freely  transferred  from  the  other 
wards  of  the  hospital  and  back  again,  and  many  will  come  voluntarily  to 
avail  themselves  of  the  special  facilities  provided  and  to  seek  the  services  of 
physicians  and  nurses  skilled  in  the  treatment  of  the  serious  forms  of  illness 
from  which  they  suffer.  Anyone  in  the  city  of  Cleveland  who  has  a  mental 
problem  to  solve  may  then  be  made  to  feel  that  this  hospital  and  its  out- 
patient department  stand  ready  to  give  their  aid.  Such  problems  may  arise 
in  adults  and  be  recognized  by  their  families  or  by  themselves,  or  they  may 
arise  in  children  and  be  recognized  by  those  responsible  for  their  care  or 
instruction.  They  may  come  to  attention  only  when  anti-social  conduct  has 
brought  them  to  the  courts.  They  may  complicate  other  difficulties  in  per- 
sonal or  social  adaptation  in  which  they  play  an  important  but  secondary 
part.  For  the  solution  of  all  such  problems,  whatever  their  nature,  the 
city  will  have  in  such  a  psychopathic  hospital  as  that  which  has  been  dis- 
cussed, the  best  type  of  medical  resource  that  has  yet  been  devised. 


Mental  Diseases  and  Deficiency 


459 


Wards  for  Mental  Patients,  Cleveland  City  Hospital — Child  in  Ward  for 
Alcoholics  and  Drug  Addicts. 


460  Hospital  and  Health  Survey 


Provisions  for  Mental  Cases  in  Other  General  Hospitals 

Lakeside  Hospital — This  important  teaching  hospital  has  no  place  for 
even  the  temporary  care  of  mental  cases.  In  Cleveland,  as  elsewhere  in  the 
United  States,  the  virtual  exclusion  of  patients  with  mental  diseases  from 
general  hospitals  is  due  to  a  fundamental  defect  in  medical  education  which 
trains  students  in  physical  disorders  and  practically  ignores  disorders  affect- 
ing the  mind. 

Dr.  Pearce  Bailey,  in  a  recent  article*,  inquires  ^vhy  problems  in  mental 
medicine  have  not  received  the  attention  which  problems  in  general  medicine 
have,  and  answers  his  question  in  the  following  words: 

"One  significant  answer  to  this  question  will  be  found  in  the  indifference 
on  the  part  of  the  medical  profession  to  nervous  and  mental  diseases.  What 
medical  school  today,  what  general  hospital,  gives  any  but  the  most  meagre 
and  grudging  representation  to  neurology  and  psychiatry?  Our  medical 
faculties  have  done  so  little  to  encourage  interest  and  knowledge  in  these 
subjects  that  some  of  the  most  important  social  features  connected  with 
them  have  been  brought  to  public  interest  by  laymen.  Indeed,  we  are  so  be- 
hind hand  in  these  matters  that  there  is  a  question  if  American  neurology 
and  psychiatry  will  ever  attain  the  position  they  should  have  unless  there 
is  established  a  special  foundation  for  research  and  teaching,  to  do  for  the 
menace  of  nervous  and  mental  disease  what  is  being  done  as  a  matter  of 
course  for  physical  diseases.  It  really  seems  that  a  care-free  foundation 
were  the  condition  for  the  firmer,  broader,  more  scientific  grasp  of  the  sub- 
jects which  bring  us  into  closer  relation  with  human  nature  than  any  others. 
Trained  men  are  wanted  everywhere,  a  wider  dissemination  of  knowledge 
is  wanted.  Men  trained  in  mental  medicine  are  needed  at  the  state  hos- 
pitals, in  the  Public  Health  Service,  in  the  courts  and  the  schools,  to  carry  on 
the  principles  of  the  few  psychiatric  clinics  thus  far  established.  Where 
are  they  to  come  from?  What  medical  school  is  in  a  position  to  train  them? 
A  great  field  of  preventive  medicine  is  before  us,  asking  for  action.  Perhaps 
in  the  past  the  proofs  of  the  need  have  not  been  plain  enough.  That  ex- 
planation no  longer  holds  good.  The  public  health  importance  of  nervous 
and  mental  diseases  no  longer  permits  of  evasion." 

The  facilities  for  teaching  mental  medicine  in  the  Medical  School  of 
Western  Reserve  University  are  neither  inferior  nor  superior  to  those  found 
in  practically  all  American  colleges.  The  academic  status  of  psychiatry — 
an  unimportant  division,  combined  with  neurology,  of  the  department  of 
general  medicine — is  in  harmony  with  the  meagre  clinical  facilities  available 
and  the  small  number  of  hours  devoted  to  the  subject  in  the  curriculum. 
The  only  wards  in  which  mental  patients  can  be  studied  by  medical  students 
are  those  at  the  City  Hospital,  where  the  most  striking  thing  to  be  seen  is  the 
neglect  with  which  mental  cases  still  can  be  treated  in  an  institution  devoted 
to  the  relief  of  the  sick.  A  rather  striking  local  occurrence  which  shows  how 
little  can  be  accomplished  when  psychiatry  is  taught  under  such  conditions 
was  afforded  by  a  trial  in  which  the  testamentary  capacity  of  a  wealthy  man 
was  the  issue.    A  recent  graduate  of  the  Medical  School,  when  placed  upon 

SMental  Hygiene,  Vol.  4,  No.  2,  April  1920. 


Mental  Diseases  and  Deficiency  461 

the  witness  stand,  attempted  to  describe  the  patient's  mental  disease  in  a 
confused  medical  jargon,  instead  of  stating  what  it  was  that  he  saw  and 
heard  which  led  him  to  make  a  diagnosis  of  mental  disorder.  The  impression 
made  on  the  court  was  that  of  a  person  attempting  to  describe  something 
he  knew  nothing  whatever  about.  A  few  minutes  later,  however,  a  bank 
clerk  who  took  the  stand  gave  a  clear,  simply-worded  account  of  his  deal- 
ings with  the  patient,  evidences  of  failing  memory,  of  delusions,  misidentifiea- 
tion  of  persons  and  other  evidences  of  a  disordered  mind. 

The  authorities  of  the  University  and  the  Medical  School  are  fully  aware 
of  the  deficiency  which  their  school  shares  with  so  many  others,  and  an 
active  movement  is  under  way  to  include  a  modern  well-equipped  university 
psychiatric  clinic  in  the  new  Lakeside  Hospital.  When  these  facilities  are 
available,  mental  cases  will  be  admitted  to  the  wards  set  aside  for  them  with 
as  little  formality  as  to  the  general  medical  or  surgical  wards  of  the  hospital, 
and  students  will  learn  their  mental  medicine  in  the  same  atmosphere  of 
science  and  kindly  care  as  that  in  which  they  learn  to  diagnose  and  treat  all 
other  types  of  illness.  With  such  provisions,  those  who  graduate  from  this 
medical  school  in  the  future  will  have  an  attidude  toward  mental  disease  very 
different  from  that  of  those  already  graduated,  who  are  carrying  into  the 
homes  and  hospitals  in  which  they  practise  a  conception  of  insanity  that 
belongs  to  a  different  century.  The  benefits  of  the  university  psychiatric 
clinic  to  others  are  even  greater  than  those  which  come  to  the  future  phy- 
sicians. The  training  school  for  nurses  of  the  parent  hospital  which  has  a 
psychiatric  department  gives  special  consideration  to  mental  nursing,  all 
pupil  nurses  spending  a  definite  period  of  their  course  of  training  in  the  mental 
wards.  The  social  service  department  of  a  university  psychiatric  clinic 
enables  the  environment  to  be  studied  as  a  factor  in  the  causes  of  disease, 
its  manifestations  or  its  outcome.  Thus,  the  hospital  is  brought  into  con- 
tact with  the  school  and  the  home  and  when  such  relations  are  established 
between  the  social  environment  in  which  mental  illness  has  its  origin  and  the 
psychiatric  hospital  in  which  it  is  studied  and  treated,  a  real  and  positive 
mental  hygiene  becomes  possible. 

Fairview  Park  Hospital — The  medical  staff  of  Fairview  Park  (formerly 
the  German)  Hospital  is  headed  by  a  neuro-psychiatrist.  A  limited  number 
of  patients  are  received  in  private  rooms  where  they  are  cared  for  skillfully 
under  his  direction.     A  mental  hygiene  clinic  is  about  to  be  opened. 

Mt.  Sinai  Hospital  has  this  year  appointed  a  neuro-psychiatrist  to  its 
staff  and  inaugurated  a  mental  hygiene  clinic. 

St.  John's  Hospital  is  able  to  take  in  a  few  mental  patients,  who  offer 
no  special  difficulties  in  treatment,  but  it  has  no  out-patient  department  for 
mental  diseases  and  no  psychiatrist. 

Lakewood  Hospital  also  receives  a  few  mental  patients,  the  physicians 
who  bring  them  into  the  hospital  being  responsible  for  their  care. 

Other  General  Hospitals — There  are  no  beds  for  mental  patients  in 
the  hospitals  not  mentioned  above,  except  the  Marine  Hospital  in  which 
there  are  a  few  beds  for  mental  patients  among  beneficiaries  of  the  Bureau  of 


46,-2  Hospital  and  Health  Survey 

War  Risk  Insurance,  but  most  of  them  have  neuro-psychiatrists  on  their  con- 
sulting staffs.  In  none,  however,  is  there  a  regular  psychiatric  service  or  clinic. 
The  neuro-psychiatrists  act  as  consultants  and  are  called  in  only  when  some 
one  feels  that  their  special  services  are  needed.  How  little  this  need  is  ap- 
parentlv  felt  is  shown  by  the  fact  that  the  neuro-psychiatrist  of  one  of  these 
hospitals  made  his  last  visit  before  he  left  to  enter  the  army  and  it  was  not 
known  at  the  hospital  whether  or  not  he  had  returned  to  Cleveland  since  the 
war.  In  another  hospital  no  psychiatric  consultations  had  been  held  or 
demanded  within  two  years. 


Dispensaries 

There  are  no  dispensaries  for  psychiatric  cases  in  Cleveland.  Were  it  not 
for  the  psychological  clinic  maintained  by  the  Board  of  Education  and  the 
work  done  by  Miss  Claire  Walters  in  connection  with  the  Boys'  Home  and 
the  Juvenile  Court,  it  would  be  necessary  to  say  that  no  organized  facilities 
existed  for  the  examination  of  mental  patients  in  out-patient  clinics.  It  is 
well  recognized  that  the  psychological  clinic  can  deal  with  only  one  phase  of 
the  problems  of  mental  diseases  and  mental  deficiency.  With  the  great 
shortage  of  institutional  provisions  that  exists  in  Cleveland  the  need  for 
dispensaries  is  much  increased.  There  is  urgent  need  for  several  well 
equipped  and  well  staffed  psychiatric  dispensaries  not  only  to  aid  the 
psychological  clinics  in  rounding  out  their  work  with  children  but  to  bring 
medical  aid  to  many  who  can  be  most  successfully  treated  in  that 
way  and  to  others  who  need  institutional  care  but  who  can  be  tided 
over  temporary  difficulties  by  the  help  that  they  can  receive  in  a 
well-conducted  psychiatric  dispensary.  The  out-patient  department  of 
the  proposed  City  Psychopathic  Hospital  will  be  one  of  its  most  useful 
activities  but  to  deal  with  such  special  problems  as  those  presented  in 
the  schools  and  courts  and  homes,  "outposts"  must  be  established  which 
can  give  as  many  hours  or  days  a  week  as  are  necessary  to  these  special 
tasks.  With  a  personnel  consisting  of  a  psychiatrist,  a  psychologist  and  a 
social  worker  such  "outposts"  can  become  extremely  valuable  diagnostic 
and  therapeutic  agencies,  especially  when  they  have  behind  them  the  wards 
and  laboratories  of  a  modern  psychopathic  hospital.  Another  such  dispen- 
sary which  should  also  maintain  its  share  of  "outposts"  should  be  established 
at  the  Lakeside  Hospital  where  it  will  greatly  increase  the  usefulness  of  the 
proposed  university  psychiatric  clinic. 


Private  Sanitaria  for  Mental  Cases 

The  number  of  patients  in  private  institutions  in  the  different  states  bears 
a  general  relation  to  the  extent  and  character  of  state  care.  Where  state 
care  is  maintained  at  a  high  level  of  efficiency,  persons  avail  themselves 
freely  of  it,  but  when  it  is  poor  in  extent  or  quality  every  effort  is  made, 
even  by  those  with  very  limited  means,  to  provide  some  kind  of  a  substitute. 
It  is  not  surprising,  therefore,  that  with  its  overcrowded  state  hospitals 
operated  at  a  very  low  cost,  Ohio  should  have  a  relatively  large  proportion 
of  patients  in  private  institutions. 


Mental  Diseases  and  Deficiency  463 

In  most  other  states  the  insane  and  mentally  defective,  whether  in  public 
or  private  institutions,  are  at  all  times  regarded  as  wards  of  the  state.  This 
is  a  practical  survival  of  the  ancient  custom  which  made  all  minors  and 
incompetent  persons  wards  of  the  Crown.  In  Ohio  no  license  whatever  is 
required  to  conduct  a  private  sanitarium  for  the  care  of  voluntary  or  com- 
mitted cases  of  mental  disease.  In  spite  of  the  efforts  of  a  former  member  of 
the  State  Board  of  Charities,  who  was  a  psychiatrist,  to  bring  such  institu- 
tions under  state  supervision,  any  person  can  start  a  sanitarium,  advertise, 
receive  patients,  lock  them  in  strong  rooms  or  restrain  them  in  beds  without 
any  authority  of  law.  These  sanitaria  are  not  inspected,  in  fact,  are  scarcely 
known  to  exist,  except  by  physicians.  Judges  occasionally  order  patients  to 
such  institutions  which  receive  them  on  that  specific  order,  but  thereafter 
the  state  exercises  no  supervision.  Practically  the  only  control  which  any 
state  official  has  over  these  institutions  is  that  exercised  by  the  Fire  Marshal 
who  may  declare  the  premises  unfit  for  the  purposes  for  which  they  are  used 
and  order  the  reception  of  persons  and  patients  discontinued  on  the  ground 
of  fire  hazard. 

This  lack  of  supervision  over  what  is  generally  recognized  to  be  an  ac- 
tivity in  which  the  state  has  a  very  definite  responsibility,  may  be  contrasted 
with  the  provisions  for  licensing  and  inspecting  private  institutions  which 
exist  in  New  York.  In  that  state  a  private  institution  caring  for  mental 
cases  must  secure  a  license  which  is  granted  only  after  a  careful  inspection 
by  the  psychiatrist  who  is  Medical  Inspector  of  the  State  Hospital  Commis- 
sion. The  physician-in-charge  of  a  private  institution  must  have  had  at 
least  five  years'  experience  in  the  treatment  of  mental  diseases  in  an  insti- 
tution for  the  insane.  All  cases  under  treatment  in  an  institution  must  have 
been  received  as  voluntary  patients  under  the  laws  regulating  this  form  of 
admission  or  must  have  been  committed  by  one  of  the  methods  provided  by 
law.  Such  institutions  are  frequently  inspected  and  they  must  make  the 
changes  and  improvements  ordered  by  the  State  Hospital  Commission,  in 
personnel  as  well  as  in  physical  facilities,  or  be  in  danger  of  having  their 
license  revoked. 

Nothing  that  has  been  said  above  regarding  the  necessity  for  supervising 
and  inspecting  private  sanitaria  for  the  care  of  mental  cases  should  be  taken 
to  minimize  the  valuable  part  which  the  best  of  these  institutions,  even 
though  run  for  profit,  play  in  the  treatment  of  mental  diseases.  It  would 
be  difficult  to  devise  any  other  substitute  for  patients  who  require  con- 
tinued care  and  are  able  to  pay  more  for  it  than  the  cost  of  maintenance  in 
the  state  hospitals.  There  are  certain  disadvantages  in  the  lack  of  a  large 
staff,  laboratories  and  facilities  which  characterize  the  modern  state  hos- 
pital, but  the  surroundings  of  the  good  private  institutions  are  similar  to  the 
patient's  usual  environment.  Much  more  individualized  work  is  carried  on 
in  behalf  of  those  who  have  disorders  of  long  duration,  but  with  prospects 
of  ultimate  recovery,  than  is  possible  in  the  state  hospitals,  in  which  prac- 
tically all  therapeutic  effort  is  concentrated  for  a  short  period  upon  a  rela- 
tively small  proportion  of  patients.  Several  of  the  sanitaria  for  mental 
diseases,  which  receive  patients  from  Cleveland  are  excellent  institutions, 
have  staffs  of  competent  physicians  and  nurses  and  are  able  to  provide  prac- 
tically all  the  facilities  for  treatment  which  modern  standards  demand.     On 


464  Hospital  and  Health  Survey 

the  other  hand,  others  which  often  charge  as  high  or  higher  rates  provide 
only  custodial  care  which,  in  many  instances,  is  inferior  to  that  provided  by 
a  state  hospital. 

There  is  urgent  need  of  a  change  in  legislation  which  will  enforce  in  Ohio 
the  provisions  of  the  Fifth  Amendment  of  the  United  States  Constitution, 
which  makes  it  illegal  to  deprive  any  person  of  "life,  liberty  or  property, 
without  due  process  of  law. "  Private  sanitaria  for  mental  patients  and  men- 
tally defective  children  should  receive  their  cases  by  voluntary  admission, 
commitment  for  observation,  or  regular  commitment,  as  is  the  case  with 
public  institutions.  Such  institutions  should  be  licensed,  preferably  for  a 
year  at  a  time,  after  an  inspection  of  the  plant  and  facilities  by  a  competent 
psychiatrist  and  after  approval  by  the  Bureau  of  Hospitals  of  the  State 
Department  of  Health.  Every  such  institution  should  be  subject  to  expert 
inspection  not  less  frequently  than  four  times  a  year  and  during  such  inspec- 
tions every  patient  should  be  examined  to  see  that  he  is  either  a  voluntary 
patient  or  held  under  proper  legal  authority  and  to  determine  whether  he  is 
receiving  the  treatment  which  his  condition  demands.  A  provision  should 
also  be  inserted  in  the  law  which  will  make  it  mandatory  for  the  medical 
head  of  each  such  institution  to  possess  certain  experience  in  the  care  of 
mental  disease.  It  should  be  within  the  power  of  the  licensing  board  to 
revoke  or  fail  to  renew  at  any  time  the  license  of  any  private  institution 
which  does  not  maintain  a  satisfactory  standard  of  treatment  or  which  re- 
ceives patients  through  illegal  methods  of  commitment. 


Places  Other  Than  Hospitals  for  Detention  or  Care 

County  Jail — The  county  jail  provides  for  a  small  number  of  mental  cases. 
In  the  cell  section  there  are  two  beds  in  which  prisoners  who  are  quite  ill 
physically  or  are  thought  to  be  mental  cases  are  put  for  short  periods.  For- 
merly this  was  the  only  provision  available  for  those  who  after  their  arrest 
seemed  to  present  evidences  of  abnormal  mental  condition.  Largely  through 
the  efforts  of  Judge  Alexander  Hadden  of  the  Probate  Court,  a  room  off  the 
sheriff's  office  was  secured  and  provided  with  eight  beds.  Men  who  are 
apparently  insane,  epileptic  or  mentally  defective  are  now  put  into  this 
room.  Before  prohibition  went  into  effect  more  than  fifteen  had  been  housed 
in  this  room  at  one  time,  mattresses  being  placed  on  the  floor  and  the  patients 
placed  two  in  a  bed.  Since  prohibition  this  number  has  been  greatly  decreased 
so  that  sometimes  for  several  days  at  a  time  there  has  been  no  new  mental 
case  admitted.  When  the  jail  was  visited  there  were  two  patients  in  the 
room,  one  a  man  who  escaped  from  the  State  Hospital  at  Massillon,  and  the 
other  a  young  negro  awaiting  investigation.  These  patients  are  kept  segre- 
gated from  criminals,  and  everybody  at  the  jail  seems  to  realize  that  they 
should  have  some  special  attention.  Usually  after  one  night  spent  in  the 
jail  hospital  mental  cases  are  examined  by  one  of  the  neuro-psychiatrists 
attached  to  the  Probate  Court  and  when  their  cases  have  been  considered 
by  the  court  they  are  transferred  to  the  City  Hospital  or  other  disposition 
made.  Women  are  taken  to  the  matron's  floor  where  they  have  the  freedom 
of  a  good-sized  room  during  the  day.     At  night  they  are  put  in  cells. 


Mental  Diseases  and  Deficiency  465 

In  spite  of  the  best  provisions,  insane  persons  who  are  unable  to  give  an 
account  of  themselves  or  who  suffer  with  disorders  of  conduct  are  extremely 
likely  to  be  picked  up  by  the  police.  With  a  law  which  permits  the  admis- 
sion of  all  such  persons  to  psychopathic  wards  for  observation,  it  is  not  neces- 
sary for  such  cases  to  be  detained  in  jail  at  all.  In  fact,  in  several  states, 
provisions  of  the  insanity  law  directly  forbid  the  placing  of  an  insane  person 
or  one  in  whom  insanity  is  suspected  in  a  place  for  criminals  or  even  in  a  place 
in  which  are  to  be  found  those  accused  of  crime.  Prisoners  who  are  await- 
ing trial  or  who  exhibit  evidences  of  mental  disease  during  their  imprison- 
ment should  be  transferred  at  once  to  the  psychopathic  department  of  the 
City  Hospital  for  observation.  This  applies  to  alcoholic  cases  and  drug 
addicts  whose  arrest  cuts  off  the  supply  of  the  drug  to  which  they  are  ad- 
dicted. It  is  very  evident  that  the  jail  is  regarded  in  Cleveland  as  a  wholly 
unsuitable  place  for  persons  suffering  from  mental  disease  and,  very  properly, 
no  provision  is  made  there  for  other  than  the  most  temporary  kind  of  care. 

Mentally  defective  prisoners  are  very  unlikely  to  have  their  condition 
recognized  at  the  jail  unless  they  are  very  low  grade  defectives,  when  they 
usually  take  the  course  through  the  Probate  Court  followed  by  those  suffer- 
ing from  mental  diseases. 

With  the  routine  mental  examination  of  a  person  admitted  to  a  jail, 
such  as  is  the  practice  in  many  cities  and  is  rapidly  extending  to  others,  it 
will  not  be  necessary  to  depend  upon  the  untrained  judgment  of  the  sheriff 
and  jailers  as  to  the  mental  state  of  prisoners. 

City  Farm — On  a  large  tract  of  land  at  Warrensville,  a  short  distance 
outside  the  corporate  limits  of  the  city,  is  the  City  Farm  which  was  acquired 
upon  the  suggestion  of  Dr.  Harris  R.  Cooley,  at  one  time  Director  of  Chari- 
ties and  Corrections.  It  was  Dr.  Cooley's  plan,  as  part  of  a  general  system 
of  parole  and  reconstruction,  to  attempt  to  reclaim  prisoners  in  the  House 
of  Correction  by  giving  them  an  opportunity  for  industrial  training  on  the 
farm.  The  tract  of  land  is  so  large  that  some  of  it  was  soon  used  for  other 
purposes.  There  are  now  on  this  tract  in  addition  to  the  House  of  Correc- 
tion, the  Tuberculosis  Sanatorium  (described  in  Part  IV.  of  the  Hospital  and 
Health  Survey),  the  Girls'  Home  and  the  City  Infirmary. 

The  City  Infirmary — This  institution  provides  for  about  500  patients, 
most  of  them  advanced  in  years,  with  chronic  illnesses.  Some  are  able  to 
be  about  and  help  to  a  certain  extent  in  the  institution,  but  most  of  them  are 
too  infirm.  Cases  are  received  upon  the  order  of  the  Superintendent  of 
Out-door  Relief  after  being  referred  to  that  official  by  the  families  of  pa- 
tients, district  physicians  or  other  physicians.  The  building  is  new  and 
clean.  There  is  only  one  resident  physician  and  few  nurses,  so  the  standards 
of  scientific  care  are  not  high,  although  there  are  many  evidences  of  kind- 
ness and  interest  on  the  part  of  those  who  are  in  contact  with  the  patients. 
Specialists  from  the  Probate  Court  make  periodical  examinations  of  the 
whole  population  of  the  Infirmary  for  the  purpose  of  discovering  and  having 
"probated"  those  suffering  from  mental  diseases.  The  last  such  visit  was 
in  November,  1919,  and  another  is  expected  in  the  near  future.     The  exami- 


466  Hospital  and  Health  Survey 

nation  of  seventy  cases  indicated  that  a  number  of  patients  with  well-defined 
psychoses  will  be  found  and,  in  addition,  many  others  with  simple  senile 
deterioration  who  are  usually  not  transferred  to  the  "insane  wards. "  These 
"insane  wards"  consist  of  two  buildings  of  modern  construction,  but  show 
no  evidence  of  having  been  planned  especially  for  the  purpose  for  which 
they  are  used.  When  visited  there  were  seventy-nine  male  and  eighty-nine 
female  patients.  Windows  are  guarded  and  doors  locked.  In  general,  the 
wards  were  clean  and  not  unattractive.  Patients  are  not  received  directly 
to  these  wards,  but,  in  all  cases,  transferred  from  the  City  Hospital  or  from 
other  wards  of  the  City  Infirmary.  Theoretically,  all  are  awaiting  reception 
by  the  State  Hospital  as  soon  as  vacancies  exist.  Actually,  they  will  spend 
many  months  or  years  in  the  institution,  for  vacancies  in  the  State  Hospital 
are  used  for  the  reception  of  more  acute  cases.  These  patients  have  no 
specialist  in  mental  diseases  to  direct  their  care  and  no  trained  nurses.  At- 
tendants who  are  paid  from  $42.00  to  $50.00  per  month,  with  maintenance, 
are  employed.  These  attendants,  as  is  so  often  the  case,  make  up  in  kind- 
ness and  thoughtfulness  much  that  they  lack  through  not  having  had  special 
training. 

These  "insane  wards"  are  purely  custodial.  They  represent  another 
period  in  the  history  of  the  care  of  the  insane,  and  exist  only  because,  pending 
the  state's  tardy  recognition  of  its  duty  in  the  matter,  Cleveland  is  content 
to  allow  some  of  its  citizens  wjio  suffer  from  serious  diseases  to  be  held  in  a 
custodial  institution  without  treatment.  Sane  patients  are  sometimes  trans- 
ferred from  the  other  wards  of  the  City  Infirmary  to  the  "insane  wards"  for 
"discipline,"  a  practice  unfair  alike  to  the  insane  and  to  those  who  are  trans- 
ferred. 


Mental  Diseases  and  Deficiency  467 

State  Facilities  for  Diagnosis  and  Treatment 

IN  every  state  the  care  of  mental  diseases  is  very  largely  dependent 
upon  legal  and  administrative  mechanisms  set  up  by  the  legislature. 
A  community  may  possess  an  enlightened  and  humane  conception  of 
its  duty  toward  its  mentally  ill  but  such  a  conception  can  be  expressed  only 
through  such  mechanisms.  In  all  other  diseases  no  such  situation  exists. 
It  is  for  this  reason  that  a  study  of  the  facilities  for  dealing  with  mental 
diseases  and  mental  deficiency  in  Cleveland  must  take  into  consideration 
the  laws,  administrative  agencies  and  institutions  that  the  state  of  Ohio 
has  provided. 

State  Board  of  Administration 

The  form  of  institutional  administration  and  supervision  in  Ohio  is  that 
known  as  the  "State  board  of  control  system. "  In  this  system  all  authority 
is  placed  in  the  hands  of  the  few  men  constituting  the  central  board,  and  the 
institutions  have  no  local  boards  of  managers.  In  Ohio  this  board  is  called 
the  State  Board  of  Administration.  It  is  a  bi-partisan  body  consisting  of 
four  members,  each  of  whom  receives  $5,000  a  year  for  full-time  service. 
The  term  of  office  is  four  years.  Members  are  appointed  by  the  Governor 
with  the  advice  and  consent  of  the  Senate.  In  spite  of  the  fact  that  by  far 
the  larger  number  of  persons  in  the  twenty-one  institutions  under  the  control 
of  the  Board  are  suffering  from  serious  forms  of  illness,  the  law  does  not  re- 
quire that  a  physician  shall  be  one  of  the  members,  nor  even  for  any  medical 
consultation  in  the  work  of  the  Board.  The  medical  superintendents  of 
state  institutions  are  directly  under  the  Board.  When  the  medical  profes- 
sion demanded  representation,  a  physician  was  appointed  to  the  Board. 
Business  administration  is  centered  in  the  Board  so  there  are  no  stewards  in 
the  hospitals.  This  places  a  heavy  burden  of  business  detail  upon  the  medical 
superintendents  of  these  institutions.  There  is  no  provision  for  coordinat- 
ing the  scientific  work  of  the  hospitals,  no  central  institute  for  research  and 
training  and  no  feeling  on  the  part  of  the  Board  that  it  is  responsible  for 
leadership  in  the  very  important  and  complex  relationships  which  mental 
diseases  and  mental  deficiency  bear  to  social,  health  and  educational  prob- 
lems. A  harsh  and  unwieldy  commitment  law  is  permitted  to  remain  on 
the  statute  books  as  far  as  any  action  initiated  by  the  Board  is  concerned, 
and  the  whole  system  of  administration  is  based  upon  the  conception  that 
the  duty  of  the  state  toward  its  citizens  with  mental  diseases  and  mental 
deficiency  begins  and  ends  with  institutional  administration.  Of  course  the 
period  of  institutional  treatment  represents  only  one  phase  of  a  life-time  prob- 
lem in  the  insane  and  mentally  defective,  and  no  administrative  mechanism 
which  limits  its  interest  to  the  institutional  phase  (and  practically  only  to 
the  business  side  of  this  phase)  can  establish  clinics,  develop  social  service 
and  after-care  for  patients  and  take  leadership  in  practical  work  for  preven- 
tion. In  states  which  have  special  medically  led  commissions  to  direct  the 
state  care  of  the  insane  and  mentally  defective,  all  these  activities  constitute 
a  large  part  of  the  service  rendered,  while  at  the  same  time  business  adminis- 
tration is  competently  directed.  At  present  many  states  are  firmly  committed 
to  the  "Board  of  Control  Idea,"  but  in  several,  efforts  are  being  made  to  cor- 
rect the  serious  deficiencies  of  such  a  system  by  appointing  physicians  as 


•468  Hospital  and  Health  Survey 

special  advisors  in  the  part  of  their  work  that  deals  with  mental  diseases, 
mental  deficiency  and  tuberculosis.  Even  with  such  modifications  this  sys- 
tem does  not  permit  the  kind  of  work  in  treatment  and  prevention  that 
modern  conception  of  mental  diseases  and  mental  deficiency  makes  obligatory 
upon  a  state  that  faces  these  problems  squarely  and  seeks  to  do  more  than 
temporize  with  them. 


Laws  Relating  to  the  Insane,   Mentally  Defective  and  Epileptic 

Insane — The  laws  of  Ohio  require  that  when  any  person  is  believed  to  be 
insane,  or  because  of  insanity  is  "dangerous  to  the  community  at  large,"  a 
formal  complaint  be  made,  a  warrant  issued  for  the  apprehension  of  the 
alleged  insane  person,  and  the  accused  brought  before  the  court  or  examined 
by  the  Probate  Judge  out  of  court.  This  procedure  emphasizes  the  legal  side 
of  mental  disease,  adding  a  considerable  burden  to  the  already  troubled  minds 
of  the  unfortunate  patients,  who  often  are  perplexed  that  they  should  be 
arrested  when  they  have  committed  no  crime.  As  stated,  the  judge  may 
review  the  case  at  the  residence  of  the  patient  or  elsewhere,  but  naturally 
this  is  seldom  done.  The  judge  obtains  such  evidence  of  the  patient's  in- 
sanity as  he  deems  necessary  and  must  cause  a  certificate  to  be  made  by  two 
medical  witnesses.  Being  satisfied  that  the  person  is  insane,  the  court  applies 
to  the  superintendent  of  the  state  hospital,  asking  that  the  patient  be  received. 
Lpon  notice  from  the  superintendent,  the  judge  directs  the  sheriff  to  transfer 
the  patient  to  the  state  hospital.  A  suitable  female  assistant  must  accom- 
pany him  if  the  patient  is  a  woman.  If  there  is  a  vacancy  in  the  county's 
quota  at  the  hospital,  the  Probate  Judge  may  commit  an  acute  case  without 
notice.  If  the  relatives  of  an  insane  person  desire  to  take  charge  of  him  they 
may  do  so  with  the  court's  approval.  Voluntary  commitments  are  permitted 
for  not  more  than  sixty  days,  and  no  hospital  is  permitted  to  care  for  more 
than  five  voluntary  patients  at  one  time,  nor  for  any  if  the  county's  quota 
is  already  full.     There  is  no  provision  for  emergency  commitments. 

Patients  may  be  allowed  out  on  trial  visits  not  exceeding  ninety  days  in 
length.  These  visits  are  made  under  rules  prescribed  by  the  Board  of  Ad- 
ministration, but  the  decision,  except  in  criminal  cases,  rests  in  the  hands  of 
the  superintendent.  When  an  insane  criminal  is  in  condition  suitable  for 
discharge,  the  prosecuting  attorney  of  the  county  whence  he  came  must  be 
informed.  The  question  of  insanity  may  be  introduced  as  a  defense  in  crim- 
inal actions  and  determined  by  the  jury  sitting  in  the  case  or  by  jury  specially 
called,  in  which  event  the  prisoner  is  usually  transferred  to  the  jurisdiction 
of  the  Probate  Court  so  that  he  may  be  placed  in  a  state  hospital.  The  trial 
judge  may  commit  him  if  his  release  is  deemed  dangerous  to  the  public 
peace  or  safety.  Similarly  if  a  person  before  a  court  in  any  capacity  appears 
to  be  insane,  a  jury  may  be  empowered  to  decide  his  mental  state,  or  he  may 
be  transferred  to  the  Probate  Court  for  its  determination.  The  latter  is  the 
usual  procedure.  Criminal,  convict,  dangerous  and  "incorrigible"  insane 
who  cannot  be  conveniently  cared  for  at  other  hospitals  for  the  insane,  and 
insane  persons  who  have  previously  been  convicted  of  certain  serious  crimes 
are  cared  for  at  the  Lima  State  Hospital  for  the  Criminal  Insane. 


Mental  Diseases  and  Deficiency  469 

None  but  residents  of  the  state  can  be  received  into  a  state  hospital, 
except  upon  order  of  the  State  Board  of  Administration. 

The  Ohio  law  does  not  reflect,  as  the  laws  of  many  other  states  now  do, 
the  great  changes  in  medical  and  public  opinion  regarding  mental  illness 
and  those  who  suffer  from  it  that  have  come  about  during  the  last  genera- 
tion. The  provision  for  a  quota  for  each  county  legally  recognizes  failure 
to  provide  free  state  care.  The  requirement  of  personal  appearance  before 
a  judge  imposes  the  hardships  of  a  quasi-criminal  procedure  upon  sick  people. 
The  provision  limiting  the  number  of  voluntary  cases  to  five  is  not  observed 
by  most  hospital  superintendents.  In  the  absence  of  vacancies  for  cases 
awaiting  admission  after  court  commitment  such  a  provision  serves,  never- 
theless, to  restrict  the  use  of  the  most  desirable  type  of  commitment  pro- 
cedure. 

The  laws  relating  to  the  insane  should  be  thoroughly  revised  so  as  to 
permit  personal  appearance  or  even  service  to  be  waived,  to  provide  for 
emergency  commitment  and  commitment  for  observation,  and  to  remove  the 
restrictions  thrown  about  voluntary  admission.  The  law  should  provide  for 
attendants  from  the  state  hospitals  going  to  the  homes  and  bringing  in  new 
patients,  thereby  eliminating  the  sheriff  entirely. 

Mentally  Defective  and  Epileptic — Proceedings  in  committing  the 
feeble-minded  and  epileptic  are  practically  identical  with  those  followed  in 
cases  of  insanity,  and  there  is  the  same  emphasis  on  a  hearing  before  a  judge. 
There  is  the  same  provision  for  the  reception  of  epileptics  as  voluntary  pa- 
tients, and  parents  and  guardians  may  voluntarily  ask  that  their  charges 
be  admitted  into  the  Institution  for  the  Feeble-minded  at  Columbus,  Ohio. 
The  Board  of  Administration  may  also  make  commitments  to  that  institu- 
tion. Medical  certificates  for  these  institutions  and  the  state  hospitals  are 
alike. 

With  the  mentally  defective  and  epileptic,  as  with  the  insane,  the  object 
of  the  commitment  law  should  be  to  make  the  institutions  readily  accessible 
to  those  who  need  their  services,  throwing  around  the  procedure  only  such 
safeguards  as  experience  has  shown  to  be  necessary  to  prevent  abuse.  The 
self-respect  and  welfare  of  those  committed  should  be  the  chief  consideration. 
In  the  care  of  the. mentally  defective  and  epileptic,  voluntary  commitment 
should  be  so  provided  for  as  to  become  the  method  of  election. 


State  Hospital  for  Mental  Diseases 

There  are  six  civil  state  hospitals  and  an  institution  for  the  criminal 
insane  in  Ohio.  Hamilton  County  (Cincinnati)  has  a  hospital  as  large  as 
one  of  the  state  hospitals,  which  is  owned  by  the  county  but  maintained  by 
the  state.  The  state  hospitals  at  Cleveland,  Columbus,  Dayton  and  Toledo 
receive  nearly  all  their  patients  from  the  cities  in  which  they  are  situated. 
In  many  states  the  great  public  institutions  for  the  insane  are  remote  from 
large  cities.  The  Ohio  plan  has  several  marked  advantages.  Few  states 
in  the  country  have  an  arrangement  whereby  a  system  of  state  psychopathic 
hospitals  forming  departments  of  existing  state  hospitals  could  be  put  into 


470  Hospital  and  Health  Survey 

operation  so  readily  or  be  likely  to  operate  with  as  much  success.  The  favor- 
able location  of  these  hospitals  not  only  renders  them  readily  accessible  but 
also  makes  it  possible  to  carry  on  after-care  supervision  with  great  facility. 
The  over-crowding,  understaffing,  low  per  capita  allowance  for  maintenance, 
and  the  unsympathetic  control  by  a  board  of  business  administration,  makes 
it  impossible,  however,  to  take  advantage  of  these  favorable  circumstances. 

The  Cleveland  State  Hospital  owes  its  origin  to  a  gift  of  a  tract  of 
100  acres  lying  within  the  city  limits  by  Thomas  Garfield  and  his  wife,  for 
the  purpose  of  establishing  a  hospital  for  the  insane.  The  reception  of  pa- 
tients commenced  in  1855.  The  growth  of  the  city  has  made  land  so  valu- 
able that  the  hospital  cannot  expand.  As  the  buildings  are  old  and  in  poor 
repair  it  would  be  sound  economy  to  abandon  them,  retaining  only  a  recep- 
tion hospital,  acute  medical  and  surgical  hospitals  and  a  diagnostic  clinic. 
Such  a  center  for  intensive  medical  treatment  of  not  more  than  500  beds 
would  provide  facilities  for  an  institution  of  1,500  which  should  be  situated 
within  twenty  miles  from  the  city  where  land  is  cheaper  and  more  outdoor  life 
possible.  The  experience  of  states  in  which  full  state  care  is  provided  shows 
that  the  ratio  of  patients  to  population  under  such  conditions  is  approxi- 
mately three  to  one  thousand.  In  states  like  New  York  and  Massachusetts 
in  which  full  state  care  has  been  provided  for  many  years  and  people  make 
the  fullest  possible  use  of  the  state  hospitals,  the  ratio  rises  to  four  per  1,000. 
Every  group  of  500,000  people  requires  a  state  hospital  of  1,500  beds.  There- 
fore the  district  in  which  Cleveland  is  situated  (Cuyahoga,  Lake  and  Geauga 
Counties)  requires  a  second  state  hospital,  which,  like  the  first,  could  be 
utilized  for  the  intensive  medical  treatment  suggested.  With  the  growth  of 
the  city  these  hospitals  could  be  increased  in  size  to  2,000  each  or  possibly  to 
2,500.  When  the  latter  number  is  reached,  with  the  intensive  treatment 
group,  there  will  be  5,500  beds,  which  would  provide  for  a  city  of  1,650,000 
population.  No  provisions  short  of  these  will  relieve  the  situation  that  exists 
and  end  the  reproach  of  detaining  mental  patients  in  such  places  as  the  City 
Infirmary,  because  the  state  has  made  too  little  provision,  and  of  sending 
them  back  to  their  homes  because  the  courts  will  deal  with  only  such  cases 
as  can  be  provided  for. 

Cleveland  gets  but  little  relief  from  other  state  hospitals.  When  visited 
by  the  Survey  investigator  the  Cleveland  State  Hospital  had  1,737  patients. 
There  were  only  55  patients  from  Cleveland  in  all  other  state  hospitals, 
except  that  for  the  criminal  insane  at  Lima,  where  there  were  219.  The 
ratio  of  patients  to  population  in  the  whole  state  was  one  to  423.5  and  the 
ratio  of  patients  from  Cleveland  to  the  population  of  the  city,  one  to  497.3. 
It  is  obvious  that  Cleveland  has  17  per  cent  fewer  beds  than  its  quota  in 
the  state  hospitals.  The  1,737  patients  in  the  Cleveland  State  Hospital 
were  occupying  space  alloted  to  1,450,  causing  an  overcrowding  of  nearly 
20  per  cent.  The  original  allotment  is  based  upon  a  distressingly  small 
floor  space  and  it  is  not  difficult  to  picture  the  conditions  that  exist  when 
this  space  is  occupied  by  20  per  cent  more  patients  than  the  number  for  which 
it  was  designed.  Even  to  maintain  the  population  with  this  amount  of 
overcrowding  and  to  receive  new  cases  it  is  necessary  to  send  out  many 
patients  still  unrecovered.  No  policy  could  be  more  unsound  economically 
than  this.     The  number  of  physicians  in  comparison  with  the  number  of 


Mental  Diseases  and  Deficiency  471 

patients  in  this  hospital  is  one  to  485,  one  of  the  lowest  ratios  in  the  United 
States  and  little  greater  than  that  of  physicians  to  the  general  population  in 
the  city  of  Cleveland.  If  one  disregards  entirely  the  need  of  physicians  to 
treat  the  mental  diseases  from  which  the  patients  suffer,  he  can  gain  some  idea 
of  the  standards  of  medical  work  possible,  when  he  realizes  that  these  patients 
are  so  ill  physically  that  10  per  cent  die  each  year.  The  population  of  a 
hospital  gives  a  less  adequate  idea  of  the  amount  of  medical  work  that  has 
to  be  done  than  the  admission  rate.  In  1919,  617  patients  were  admitted  to 
this  hospital.  No  state  hospital  of  the  same  size  in  the  whole  country  re- 
ceived so  many.  The  superintendent,  who  is  a  well-trained  physician,  re- 
ceives only  $2,500  a  year,  which  is  less  than  the  amount  received  by  a  recent 
graduate  in  medicine  as  junior  assistant  in  some  other  states.  The  appropri- 
ations for  maintenance  are  in  proportion.  Few  institutions  in  the  United 
States  spend  as  little  for  their  patients'  maintenance  and  care.  In  1919  the 
rate  per  annum  per  capita  for  medical,  surgical  and  laboratory  supplies  was 
19.4  cents.  In  this  hospital  approximately  180  patients  die  every  year. 
If  the  entire  appropriation  for  medical,  surgical  and  laboratory  supplies  had 
been  expended  last  year  upon  these  180  patients,  each  would  have  had  $2.20 
worth  of  such  sick  room  necessities  during  his  or  her  last  illness.  The  super- 
intendent is  trying  in  the  face  of  these  conditions  to  make  his  institution  a 
hospital  in  fact  as  well  as  in  name.  He  plans  to  re-institute  a  training  school 
for  nurses,  develop  a  system  of  after-care  and  make  the  best  possible  use  of 
his  meagre  staff  and  equipment.  He  will  inevitably  fail  if  the  people  of 
Cleveland  are  unable  to  induce  the  legislature  to  change  the  policy  of  neglect 
that  keeps  its  work  upon  the  asylum  level. 


State  Institution  for  the  Feeble-minded 

The  "Institution  for  the  Feeble-minded,"  the  only  one  in  the  state, 
was  established  in  1857  and  opened  in  August  of  that  year  in  rented  buildings 
in  Columbus,  Ohio.  It  removed  to  its  present  location  in  West  Columbus 
in  1868.  In  1898  the  legislature  appropriated  funds  for  the  purchase  of  the 
Custodial  Farm  of  1,248  acres  at  Orient. 

June  30,  1918,  there  were  2,264  inmates.  Additional  buildings  about  to 
be  opened  and  others  immediately  constructed  will  care  for  864  more,  giving 
accommodation  for  3,128.  This  is  the  largest  institution  of  the  sort  in  the 
world. 

The  state  of  Ohio  is  hardly  doing  more  than  touching  the  surface  of  the 
problem  of  mental  deficiency.  With  a  population  of  5,393,000,  a  conserva- 
tive estimate  would  place  the  number  of  feeble-minded  in  the  state  at  at  least 
21,000  (four  per  thousand),  of  whom  not  less  than  10,000  require  care  in 
special  institutions.  Provision  is  made  for  less  than  one-third  of  this  number. 
What  of  the  other  two-thirds  who  should  have  such  care?  Many  of  them, 
as  feeble-minded  children  in  the  public  schools,  juvenile  courts,  reformatories 
and  orphanages,  or  as  feeble-minded  adults  in  the  county  jails,  state  prisons, 
criminal  courts,  venereal  clinics  and  almshouses,  are  yearly  a  source  of  vast 
expense  and  the  cause  of  untold  sorrow. 


472  Hospital  and  Health  Survey 

With  an  estimated  population  of  about  one  million,  Cleveland  District 
has  about  4,000  feeble-minded  persons,  each  of  whom  possesses  potentiali- 
ties for  delinquency  and  dependency  that  justify  a  serious  effort  on  the  part 
of  public  authorities  to  recognize  and  deal  properly  with  the  problems  these 
individuals  present. 

The  advantages  of  early  recognition  and  diagnosis,  intensive  special  class 
training,  and  either  wise  and  careful  supervision  out  in  the  community  or 
adequate  institutional  care,  should  be  offered  to  each  feeble-minded  child  in 
the  state. 

It  is  not  enough  to  place  these  defective  children  in  special  classes  for  a 
few  hours  of  the  day  over  a  period  of  a  few  years,  and  then  suddenly  dump 
them  into  the  community  without  proper  oversight  or  supervision  in  early 
adolescence — the  most  unstable  and  critical  period  of  life  even  for  those  not 
so  handicapped  mentally.  The  sad  combination  of  the  defective's  childish 
mind  and  his  adult  years  inevitably  brings  him  into  conflict  with  laws  and 
rules  of  conduct  which  have  been  devised  for  persons  whose  minds  as  well  as 
bodies  are  those  of  adults. 

Much  of  the  benefit  to  be  derived  from  special  classes  in  Cleveland  is 
being  lost  through  lack  of  proper  oversight  after  school  hours  and  adequate 
supervision  of  the  child  in  the  community.  The  special  class  should  be  used 
not  merely  to  relieve  the  grades  of  a  drag  and  the  regular  grade  teachers  of 
an  apparently  hopeless  burden,  not  for  awakening  interest  and  developing 
the  general  intelligence  of  the  child,  but  to  prepare  and  fit  the  defective  to 
do  something  useful  in  life. 

Some  state  authority  should  be  charged  with  the  supervision  of  all  mental 
defectives  who  are  in  need  of,  but  not  receiving  it.  On  leaving  the  special 
class,  employment  suited  to  his  vocational  interest  and  aptitudes  should  be 
secured  for  each  of  these  children.  All  those  unable  to  profit  by  special  class 
training  or  incapable  of  being  adequately  supervised  in  the  community, 
should  receive  institutional  care,  but  those  defectives  whose  character,  make- 
up and  personality  give  them  a  definite  community  value,  who  are  self- 
supporting,  and  are  neither  a  danger  to  themselves  nor  the  general  public, 
can  and  should  be  handled  satisfactorily  under  outside  supervision. 

The  fact  that  many  high  grade  defectives,  after  prolonged  institutional 
life  and  occupational  training,  can  be  paroled  with  perfect  satisfaction  into 
the  community,  has  now  been  well  demonstrated  by  Dr.  Fernald  at  Waverley, 
Dr.  Wallace  at  Wrentham,  Dr.  Bernstein  at  Rome,  and  many  other  leaders 
in  work  among  the  feeble-minded.  Dr.  Fernald  recently  made  a  study  of 
all  male  patients  paroled  from  Waverley  in  the  last  twenty-five  years.  It  was 
found  that  the  great  majority  of  these  boys  had  never  been  arrested,  never 
been  in  court,  never  had  children,  but  were  law-abiding,  self-supporting  citi- 
zens. Few  had  married.  The  economic  saving  through  a  well-developed  parole 
system  is  enormous  but  it  is  necessary  to  emphasize  the  point  that  such  super- 
vision must  rest  upon  a  carefully  made  diagnosis  by  experts.  With  this  a 
period  of  institutional  training  is  usually,  but  not  always,  required. 


Mental  Diseases  and  Deficiency  473 

Two  outstanding  needs  deserve  mention:  (1)  identification  and  special 
class  training,  with  proper  after-care  and  supervision  for  all  children  in  the 
state  who  are  capable  of  receiving  it;    (2)  increased  institutional  provision. 

The  first  requires  a  comprehensive  mental  deficiency  law  for  the  state 
and  the  careful  upbuilding  of  the  local  mechanisms  by  which  such  a  law  may 
be  made  effective.  The  appropriation  of  $650,000  which  is  available  will 
procure  the  site,  provide  for  water  supply,  sewage  disposal,  power  plant, 
administrative  and  service  buildings  for  a  new  institution,  but  at  least  $1,350,- 
000  more  will  be  needed  for  an  institution  housing  2,000  patients.  With 
such  provisions  Ohio  will  still  be  behind  other  states  in  the  number  of  beds 
compared  to  the  general  population,  but,  with  two  such  "parent"  institu- 
tions, extension  by  means  of  colonies  may  be  cheaply  and  efficiently  made. 


State  Hospital  for  Epileptics 

The  Ohio  Hospital  for  Epileptics  at  Gallipolis,  opened  in  1893,  was  the 
first  institution  in  this  country  for  the  care  of  epileptics.  The  example  was 
followed  in  many  different  states.  The  census  of  this  institution  at  the  end 
of  the  last  fiscal  year  was  1,587.  On  April  2,  1920,  there  were  191  patients 
from  Cuyahoga  County.  This  number  represents  a  ratio  much  less  than 
that  which  the  population  of  Cleveland  bears  to  that  of  the  whole  state,  but 
cities  have  many  resources  in  their  dispensaries  and  clinics  for  the  treatment 
of  epilepsy,  and  in  the  absence  of  full  state  provisions  it  is  not  unfair  that  the 
cities  should  have  a  smaller  proportion  of  the  beds  available  in  state  institu- 
tions than  rural  communities.  Additional  provisions  for  456  patients  are 
here  being  made.     A  second  institution  of  this  kind  is  already  needed. 

Formerly  a  special  class  for  epileptics  was  maintained  in  Cleveland,  but 
it  was  discontinued  for  reasons  that  could  not  be  ascertained.  Epileptic 
children  have  needs  that  cannot  always  be  met  in  the  special  classes  for  the 
mentally  defective.  Although  many  of  them  are  mentally  defective  from 
birth  or  are  dulled  intellectually  by  their  disease,  there  are  others  suffering 
from  epilepsy  wTho  are  normally  bright.  Their  seizures  make  it  necessary 
to  exclude  such  children  from  the  grade  classes,  as  nothing  is  much  more  dis- 
tressing for  other  children  to  witness  than  a  severe  epileptic  convulsion,  but 
they  are  capable  of  carrying  on  grade  work.  The  result  is  that  many  leave 
school  altogether  at  an  early  age  and,  in  addition  to  the  heavy  burden  of 
their  epilepsy,  carry  the  additional  one  of  illiteracy.  It  would  seem  that  in 
a  school  population  of  144,197  several  special  classes  for  epileptics  would  be 
amply  justified. 


Bureau  of  Juvenile  Research 

The  Bureau  of  Juvenile  Research  was  established  on  July  1,  1914,  under 
the  following  broad  provision  of  law: 

"All  minors,  who,  in  the  judgment  of  the  Juvenile  Court,  require  state 
institutional  care  and  guardianship,  shall  be  wards  of  the  state  and  shall  be 


474  Hospital  and  Health  Survey 

committed  to  the  care  and  custody  of  the  Ohio  Board  of  Administration, 
which  Board  thereupon  becomes  vested  with  the  sole  and  exclusive  guardian- 
ship of  such  minors."     (Ohio  G.  C,  Section  1841-1.) 

The  Board  of  Administration  commits  these  minors  to  the  Bureau  of 
Juvenile  Research  for  study  and  classification  and  is  required,  after  their 
condition  has  been  determined,  to  "then  assign  the  child  to  a  suitable  state 
institution  or  place  it  in  a  family  under  such  rules  and  regulations  as  may  be 
adopted.''  The  Board  of  Administration  has  authority  to  transfer  minors 
from  one  institution  to  another  upon  proper  cause  with  the  proviso  that 
"except  as  otherwise  provided  by  law,  no  person  shall  be  transferred  from  a 
benevolent  to  a  penal  institution."  This  permits  the  Board  to  transfer  a 
child  from  the  institution  in  its  jurisdiction  to  the  Bureau  of  Juvenile  Re- 
search and  later  to  re-transfer  him.  Further  provision  is  made  for  the  re- 
ception by  the  Bureau  of  minors  from  public  institutions  not  supported  by 
the  state,  from  private  charitable  institutions,  or  from  the  custody  of  legal 
guardians,  upon  terms  deemed  proper.  The  counties  liable  for  the  support 
of  these  minors  are  required  to  pay  the  expenses  of  their  transportation. 

The  special  defect  of  this  generally  admirable  law  is  that  it  provides  for 
the  review  of  cases  that  have  already  been  passed  upon  by  the  courts.  Obvi- 
ously, the  examinations  are  most  needed  before  trial  rather  than  after  com- 
mitment. It  will  be  noted  that  only  cases  which  require  institutional  care 
are  to  be  sent  to  this  Bureau  by  the  Juvenile  Courts.  This  restriction  is 
undesirable,  for  the  hope  of  correcting  delinquent  trends  in  the  mentally 
defective  and  of  dealing  successfully  with  psychopathic  or  psychoneurotic  chil- 
dren, lies  in  making  the  greatest  efforts  in  the  early  stages  before  departures 
from  normal  behavior  are  so  striking  that  they  are  easily  recognized,  and  be- 
fore it  is  certain  that  institutional  care  is  the  most  desirable  measure.  Those 
interested  in  the  problem  of  conduct  disorders  in  childhood  desire  to  have 
all  Juvenile  Court  cases  examined  with  regard  to  the  mental  factors  in  their 
delinquency.  The  present  director  of  the  Bureau,  Dr.  H.  H.  Goddard,  has 
well  said: 

"In  a  great  many  cases,  the  first  offenders  are  as  feeble-minded  or  psy- 
chopathic as  others  and  there  is  no  good  reason  why  we  should  wait  until 
they  have  made  a  second  or  third  attempt  before  we  should  recognize  their 
condition  and  proceed  to  treat  it." 

The  Board  of  Administration  and  the  Bureau  of  Juvenile  Research  in- 
terpret this  law  in  the  broadest  possible  way  and  endeavor  to  render  as  much 
service  as  possible  to  the  children  sent  by  parents  or  institutions.  The  work 
of  the  Bureau  has  been  much  handicapped  by  insufficient  funds.  Good 
buildings  with  a  capacity  for  150  patients  exist  but  there  is  sufficient  money 
to  care  for  only  40  at  a  time,  and  at  present  there  are  less  than  that  number 
at  the  Bureau.  Its  work  is.  very  much  embarrassed  by  the  fact  that  the 
Institution  for  Feeble-minded  is  overcrowded,  so  that  a  mentally  defective 
child  must  wait,  after  his  examination,  until  there  is  a  vacancy  before  he  can 
be  admitted,  and  further  embarrassment  is  due  to  the  fact  that  there  are 
no  facilities  in  the  state  for  the  treatment  of  psychopathic  and  psycho- 
neurotic children. 


Mental  Diseases  and. Deficiency  475 

The  Director  supplies  the  following  concise  statement  of  the  personnel 
in  his  organization. 

"The  organization  at  present  is  as  follows:  director,  chief  psycho- 
clinician,  who  is  responsible  for  all  under  mental  diagnosis;  two  associate 
clinicians,  who  are  next  to  the  chief  in  ability  and  also  capable  of  making 
diagnosis;  then  two  assistant  psycho-clinicians  of  somewhat  less  experience, 
but  able  to  make  accurate  mental  tests  and  submit  recommendations  or 
suggestion  on  diagnosis;  a  physician  and  two  nurses  for  the  care  of  the  physical 
side;  a  chief  clerk,  record  clerk,  three  stenographers,  one  superintendent  of 
cottages,  superintendent  of  grounds,  two  attendants  and  the  night  watch." 

We  have  much  doubt  as  to  the  wisdom  of  dismissing  so  lightly  the  "phys- 
ical side"  of  such  complex  problems  as  those  which  come  to  the  Bureau  of 
Juvenile  Research  for  solution,  and  of  dealing  with  all  the  mental  factors 
from  a  purely  psychological  approach.  Even  if  the  defectives  present  no 
special  problem  with  which  the  psychiatrist  is  best  equipped  to  deal,  the 
psychopathic,  psychotic  and  psychoneurotic  children  must  present  many 
difficulties  upon  which  mental  medicine  has  some  light  to  throw. 

It  will  be  most  unfortunate  if  this  highly  important  experiment  station 
fails  to  render  the  service  of  whicL  it  is  capable  through  lack  of  sufficient 
funds.  When  one  contrasts  the  few  thousands  of  dollars  required  for  its 
maintenance  with  the  millions  that  are  almost  blindly  expended  in  dealing 
with  the  consequences  of  our  unintelligent  way  of  approaching  conduct 
disorders  of  childhood  and  adolescence,  it  is  obvious  that  considerations  of 
economy  alone  would  demand  generous  support  of  this  Bureau. 


476  Hospital  and  Health  Survey 

Courts  and  Correctional  Agencies 

MENTAL  diseases  and  mental  deficiency  differ  from  other  problems 
of  health  and  medicine  because  of  the  fact  that  their  diagnosis, 
management  and,  to  a  very  large  extent,  the  success  with  which 
they  may  be  dealt  by  physicians,  teachers,  nurses  and  social  workers  is  de- 
termined by  courts  and  correctional  agencies.  There  is  no  doubt  that  these 
disorders  come  to  attention  much  more  frequently  for  other  reasons  than 
that  of  disturbance  of  conduct.  Such  disturbances,  when  they  do  occur, 
however,  are  so  important  socially  and  sometimes  so  tragic  in  their  con- 
sequences that  mental  disorders  generally  are  dealt  with  by  a  legal  mechan- 
ism suitable  for  only  a  small  percentage  of  all  persons  who  are  mentally  ill. 
The  physician,  therefore,  has  to  call  upon  the  courts  when  mental  cases  are 
brought  to  his  attention,  even  though  there  is  no  question  whatever  of 
public  order  or  safety.  Very  often,  in  other  cases,  the  courts  have  gone  a 
long  way  in  determining  the  future  of  mental  patients  before  the  advice  of 
physicians  is  sought  at  all. 

Courts 

Probate  Court — The  Probate  Court  is  especially  charged  with  the 
duty  of  dealing  with  mental  patients.  The  Commitment  Law  of  Ohio  has 
already  been  referred  to  (page  468).  When  an  affidavit  alleging  insanity 
has  been  presented,  the  Judge  orders  a  "suitable  person"  usually  the  sheriff 
or  a  deputy,  to  bring  the  patient  to  court.  Patients  are  also  referred  to  the 
Probate  Court  from  other  courts  in  which  they  have  been  found  to  be  insane 
but  which  are  not  empowered  to  commit  to  institutions.  In  such  cases  the 
function  of  the  Probate  Court  is  only  that  of  commitment,  the  issue  of 
insanity  having  already  been  decided. 

In  order  to  protect  himself  from  ill-advised  or  improper  applications  for 
the  commitment  of  a  patient  the  Probate  Judge  has  attached  to  his  court 
two  examining  physicians  who  have  had  experience  in  hospitals  for  mental 
diseases.  These  psychiatrists  interview  the  friends  of  the  patient,  examine 
the  patient  personally,  and  make  a  report,  usually  verbal,  to  the  Judge. 
The  Women's  Protective  Association  sometimes  makes  social  investigations 
for  the  court.  If  this  preliminary  examination  shows  that  the  patient 
suffers  from  a  mental  disorder,  the  psychiatrists  make  out  a  medical  certifi- 
cate and  the  patient  is  committed  forthwith.  If  the  Judge  deems  that  such 
action  is  inadvisable  the  case  is  dismissed.  If  the  examination  is  inconclu- 
sive and  observation  is  required  to  establish  the  diagnosis  the  Probate  Judge 
commits  the  patient  to  the  "Detention  Hospital,"  that  is,  to  the  mental 
wards  of  the  City  Hospital,  (page  446).  Previously  this  was  not  possible, 
but  some  years  ago  when  the  wife  of  a  lawyer  went  through  the  trying  ex- 
perience of  commitment  the  law  was  amended  so  as  to  permit  this  practice. 
The  Detention  Hospital  is  used  not  only  for  such  observation  cases  but  for 
those  "whose  insanity  is  likely  to  be  temporary"  and  all  "insane  persons 
who  cannot  be  committed  to  or  received  into  the  State  Hospital."  The 
overcrowding  at  the  Cleveland  State  Hospital  makes  the  latter  procedure 
necessary  in  many  cases,  but  the  overcrowded  and  unsatisfactory  state  of 
the  Detention  Hospital  often  makes  it  difficult  to  find  any  place  for  those 


Mental  Diseases  and  Deficiency  477 

who  urgently  need  care.  The  result  is  that  people  are  advised  to  take  their 
mentally  ill  relatives  home  again  and  thus  treatment  is  deferred — a  tho- 
roughly uneconomic  and  unsound  practice.  The  Probate  Judge  may  also 
commit  to  the  department  for  mental  patients  in  the  City  Infirmary  at 
Warrensville  (page  465)  or,  in  criminal  cases,  to  the  jail  hospital  (page  464). 

It  is  often  the  case,  when  the  law  is  harsh  and  public  facilities  for 
observation  and  treatment  inadequate,  that  kindness  and  sympathetic 
cooperation  on  the  part  of  those  who  administer  the  law  minimize  the  distress 
and  humiliation  that  come  to  patients.  This  is  the  case  in  Cleveland.  The 
Probate  Judge  is  considerate,  realizing  the  heavy  affliction  that  mental 
disease  brings  to  the  patients  or  to  their  families  but,  although  he  attempts 
to  soften  the  phases  of  commitment  that  smack  of  criminal  procedure,  the 
fact  that  a  person  "suspected"  of  having  a  mental  disease  is  produced  in 
court  and  usually  brought  there  by  a  sheriff  creates  an  atmosphere  that  in 
many  other  states  has  been  eliminated  from  the  admission  to  hospital  of 
persons  suffering  from  mental  illness. 

When  a  patient  is  committed  the  Court  becomes  a  supplicant  to  the 
State  Hospital  in  the  effort  to  secure  admission.  The  superintendent  of  the 
hospital  exercises  full  jurisdiction  in  this.  Preference  is  given  to  patients 
who  are  having  the  greatest  difficulty  in  getting  on  in  the  community.  Those 
with  mild  mental  disorders  are  rarely  received  when  application  is  first  made. 
Practically  no  other  course  is  possible  but  the  great  disadvantage  of  this 
method  of  solving  the  difficulty  lies  in  the  fact  that  mild  and  early  cases 
afford  the  most  promising  field  for  successful  treatment  and  many  of  the 
severe  and  late  cases  that  become  a  permanent  charge  upon  the  state  could 
make  a  full  or  a  "social"  recovery  were  treatment  available  in  time. 

The  Cost  to  the  city  of  the  medical  examinations  and  other  services 
rendered  in  the  commitment  of  mental  patients  in  the  Probate  Court  is  not 
ascertainable  from  any  published  reports.  The  Clerk  of  the  Court  kindly 
permitted  the  examination  of  the  check  book  stubs  for  the  period  of  three 
months  ending  September  10th,  1919.  This  quarter  is  somewhat  lighter 
than  the  other  three  and  so  an  estimate  of  the  yearly  cost  based  upon  this 
examination  would  give  a  total  less,  rather  than  more,  than  is  actually  the 
case.  Medical  fees  during  the  period  amounted  to  $2,209.00,  an  annual 
rate  of  $8,836.  If  these  examinations  were  made  in  the  mental  wards  of 
the  City  Hospital  under  such  conditions  as  those  that  may  be  expected  to 
exist  when  that  institution  is  transformed  into  a  real  City  Psychopathic  Hos- 
pital, such  a  contribution  would  go  far  toward  paying  the  salaries  of  all  the 
full-time  psychiatrists  needed.  In  such  a  hospital  expert  observation  would 
yield  medical  and  social  facts  of  great  value  in  determining  the  best  action 
to  be  taken  in  each  case.  If  the  present  difficulty  in  securing  prompt  ad- 
mission to  the  state  hospitals  continues,  as  it  must  for  several  years  in  spite 
of  the  most  energetic  efforts  to  correct  it  by  new  building,  the  selection  of 
cases  for  commitment  or  for  return  to  their  homes,  with  or  without  out- 
patient supervision  and  treatment,  would  be  done  in  a  more  efficient  manner 
than  is  possible  with  the  facilities  that  now  exist.  As  it  has  been  held  that 
the  mental  wards  of  the  City  Hospital  constitute  a  place  to  which  insane 
patients  may  be  legally  committed,  the  physicians  there  cannot,  obviously, 


478  Hospital  and  Health  Survey 

take  part  in  the  commitment  of  people  to  their  own  institution.  In  order 
that  the  proposed  City  Psychopathic  Hospital  in  connection  with  the  City 
Hospital  may  operate  to  the  greatest  advantage,  it  is  necessary  that  this 
and  other  provisions  of  the  law  be  changed  so  as  to  permit  commitment 
there  only  for  observation  and  temporary  treatment  on  physicians'  cer- 
tificates or  the  orders  of  any  magistrate.  This  method  of  commitment  is 
followed  with  conspicuous  success  in  New  York  City  in  the  psychopathic 
wards  of  Bellevue  and  Kings  County  Hospitals  in  the  commitment  of  more 
than  4,0Q0  patients  a  year. 

The  sheriff  receives  $1.71  for  each  patient  conveyed  to  the  Cleveland 
State  Hospital.  There  were  567  such  patients  during  1919,  for  whose  trans- 
portation he  was  paid  $969.57.  For  each  mentally  defective  person  sent  to 
the  Columbus  State  Institution  $22.83  is  paid.  Twelve  patients  were  con- 
veyed there  during  the  same  year  at  a  cost  of  $273.96,  the  remainder 
of  the  total  of  eighty-six  being  taken  by  relatives.  Twenty  patients  were 
taken  to  the  State  Hospital  for  Epileptics  by  friends  and  six  by  the  sheriff 
at  a  cost  of  $247.38  or  $41.23  each.  The  warrant  to  arrest  a  patient  entails 
a  fee  of  $1.64.     The  number  of  such  warrants  issued  was  not  ascertained. 

To  those  who  are  accustomed  to  methods  more  in  accordance  with  those 
used  with  other  sick  persons,  this  handling  of  children  and  adults  with  mental 
diseases,  feeblemindedness  and  epilepsy  by  sheriffs  and  court  attendants  is 
abhorrent.  It  is  a  relic  of  a  period  in  the  development  of  the  public  attitude 
toward  illness  that  has  no  more  place  in  an  enlightened  community  today 
than  Salem  witchcraft.  The  simplest,  kindest,  and  least  expensive  method 
is  to  have  nurses  and  attendants  from  the  institutions  to  which  patients  are 
to  be  committed  come  for  them  and  convey  them  there  by  the  skillful  and 
kindly  methods  that  their  training  so  admirably  fits  them  to  use.  No  other 
method  would  be  tolerated  by  those  who  had  seen  the  one  suggested  in  actual 
operation. 

Municipal  Court — Only  a  relatively  small  proportion  of  all  offenses  for 
which  people  are  arrested  are  serious  ones.  This  is  true  of  those  committed 
by  mentally  defective  or  psychopathic  persons  as  well  as  by  those  with  nor- 
mal mentality  and  so  the  lower  courts,  which  in  every  city  deal  with  a  vast 
amount  of  delinquency,  have  to  do  much  more  than  the  higher  courts  with 
persons  whose  asocial  conduct  is  dependent  upon  abnormal  mental  states. 
In  the  Municipal  Court  of  Cleveland  the  relationship  existing  between 
delinquency  and  psychopathic  conditions  are  not  so  fully  appreciated  as  in 
some  other  cities  nor  do  they  receive  as  much  weight  in  procedures  of  the 
court  and  in  the  dispositions  made  of  offenders.  The  work  of  the  Municipal 
Court  is  evidently  carried  on  with  earnestness  and  a  broad  spirit  of  toler- 
ance but  few  persons  brought  before  it  receive  an  expert  psychiatric  examina- 
tion. When  insanity  is  offered  as  a  plea  or  some  abnormal  mental  condition 
is  apparent  to  the  court  or  to  the  social  workers,  patrolmen  or  others  con- 
nected with  it,  prisoners  are  sent  to  the  Probate  Court  for  disposition  and 
there  they  receive  a  psychiatric  examination.  There  seems  to  be  a  belief 
that  laymen  can  pick  out  individuals  who  require  a  mental  examination  and 
that  insanity  or  mental  deficiency  that  does  not  manifest  itself  in  ways  thus 


Mental  Diseases  and  Deficiency  479 

apparent  does  not  require  to  be  taken  into  consideration.  During  a  visit  to 
this  court  a  girl  who  had  escaped  from  an  institution  in  Michigan  was  under 
examination.  Although  to  a  psychiatric  observer  there  seemed  to  be  indica- 
tions of  mental  deficiency  which  would  warrant  a  careful  examination,  the 
Court  and  the  Probation  Officer  were  quite  confident  that  the  girl  had  excel- 
lent intelligence  and  was  simply  "sulky"  and  "tough."  It  is  asserted  that 
such  conclusions  are  founded  upon  long  experience  in  dealing  with  delinquent 
types  but  it  must  be  remembered  that  this  experience  is  not  checked  by 
studying  the  results  of  examinations  made  elsewhere  by  those  specially 
trained  and  it  is  difficult  to  see  how  it  can  do  any  more  than  to  crystallize 
connections  of  normality  and  abnormality  already  formed.  In  Boston, 
Chicago  and  Philadelphia  psychiatric  clinics  in  connection  with  the  Munici- 
pal Courts  have  been  in  successful  operation  for  a  considerable  period  of 
time  and,  in  the  opinion  of  the  magistrates  presiding  over  those  courts,  con- 
stitute a  practical  adjunct  of  the  greatest  value. 

The  Probation  Officer,  Mrs.  Callaghan,  realizes  that  her  work  would  be 
aided  in  many  cases  by  access  to  psychiatric  advice.  She  has  charge  of  all 
persons  placed  on  probation,  paying  special  attention  to  the  women,  and 
renders  other  assistance  to  the  court  when  women  are  concerned.  Mrs. 
Callaghan  has  many  cases  examined  by  Miss  Claire  Walters  who  conducts 
the  psychological  examinations  at  the  Boys'  School  and  in  cases  that  are  to 
be  sent  to  the  Probate  Court  she  makes  notes  that  are  very  helpful  to  the 
psychiatrists  attached  to  that  court. 

In  a  city  as  large  as  Cleveland  a  psychiatric  clinic  in  connection  with  the 
Municipal  Court  would  be  able  to  render  valuable  service.  Nothing  is  more 
wasteful  and  ineffective  than  the  method  of  dealing  with  permanent  mental 
deficiency  or  psychopathic  conditions  by  repeated  trial  and  commitment  to 
correctional  institutions.  Where  the  actual  results  of  this  method  have 
been  carefully  studied  it  has  been  found  that,  in  many  instances,  the  cost 
to  the  community  of  dealing  with  one  such  individual  by  these  methods 
i  s  greater  than  that  of  maintaining  an  efficient  psychiatric  clinic  for  a  period 
of  years.  With  a  modern  City  Psychopathic  Hospital  as  a  center  for  all  such 
activities,  a  psychiatric  clinic  could  be  established  in  the  Municipal  Court 
which  would  have  back  of  it  all  the  scientific  resources  of  the  Psychopathic 
Hospital  and  its  facilities  for  investigation  by  those  specially  trained  in  this 
kind  of  medical  social  work. 

Parole  Board — The  Parole  Board  which  consists  of  the  Director  of 
Public  Welfare  and  the  Probation  Officer  deals  with  skill  and  discrimination 
with  cases  that  come  before  it.  From  ten  to  fifteen  prisoners  come  before 
this  Board  each  week  and  there  are  usually  about  seventy-five  cases  on 
parole.  This  number  of  cases  requires  more  time  for  thorough  investigation 
than  one  probation  officer  can  give,  and  the  work  of  the  Board  would  be  much 
aided  if  the  probation  officer  had  more  assistance.  In  the  numerous  instances 
in  which  mental  deficiency  or  some  psychopathic  condition  is  the  cause  or  a 
very  important  factor  in  the  delinquency  of  prisoners  who  come  before  the 
Parole  Board  there  is  no  psychiatric  report.  The  great  value  of  such  reports 
in  dealing  with  these  prisoners  would  amply  justify  provisions  for  mental 


480  Hospital  and  Health  Survey 

examinations  as  a  routine  measure  in  all  persons  committed  by  the  Courts 
to  the  House  of  Correction.  When  a  modern  City  Psychopathic  Hospital 
is  established  there  should  be  stationed  here  another  psychiatric  "outpost" 
consisting  of  a  psychiatrist,  a  psychologist  and  a  social  worker  who  could 
give  from  one  to  three  days  a  week  to  this  work. 

Juvenile  Court  and  the  Detention  Home — The  Juvenile  Court  of 
Cleveland  has  long  been  known  as  a  progressive  agency  conducted  in  accord- 
ance witb  enlightened  ideas  regarding  the  management  of  delinquency  among 
children.  The  present  judge  who,  in  addition,  presides  over  the  Domestic 
Relations  and  Insolvency  Courts,  has  been  at  the  head  of  the  court  for  more 
than  twenty  years.  It  is  housed,  unfortunately,  in  the  same  building  as  the 
criminal  courts,  but  in  the  new  Criminal  and  Juvenile  Court  building  which  is 
being  erected  it  will  have  a  separate  entrance  and  contact  with  the  criminal 
courts  will  be  avoided  to  a  large  extent. 

Many  avenues  are  open  to  the  Juvenile  Court  for  securing  information 
regarding  the  children  brought  before  it.  Social  workers  investigate  the 
family  and  personal  histories  and  the  Clearing  House  cooperates  in  securing 
such  information,  especially  regarding  dependency  or  delinquency  among 
families.  The  important  relationships  that  juvenile  delinquency  bear  to 
mental  deficiency  and  other  disorders  of  the  nervous  system  are  well  under- 
stood and  many  efforts  are  made  to  secure  psychiatric  and  psychological 
examinations  that  will  throw  light  upon  this  subject  in  individual  cases. 
Miss  Claire  Walters  who  is  attached  to  the  Boys'  School  makes  intelli- 
gence tests.  At  her  suggestion  the  services  of  the  psychiatrists  attached 
to  the  Probate  Court  are  employed,  children  often  being  sent  to  them  for 
mental  examinations.  At  the  Boys'  School  and  the  Detention  Home  (dis- 
cussed below)  children  are  observed  while  their  cases  are  pending  or  while 
awaiting  placement  but,  of  course,  this  observation  is  not  made  by  those 
trained  to  detect  the  most  significant  alterations  in  behavior.  The  Bureau  of 
Juvenile  Research  is  by  far  the  most  valuable  facility  possessed  by  the  court 
in  dealing  with  issues,  but,  as  was  stated  in  the  discussion  of  that  institution, 
it  receives  children  for  scientific  study  after  instead  of  before  the  issue  of 
institutional  commitment  has  been  decided. 

The  Juvenile  Court  can  dispose  of  children  brought  before  it  in  a  number 
of  different  ways.  Warning  or  reprimanding  the  children,  warning  or  fining 
their  parents  and  parole  to  a  parole  officer  are  the  methods  employed  in  by 
far  the  greater  number  of  cases.  Boys  may  be  committed  to  the  Boys'  School, 
the  State  Industrial  School  for  Boys,  or  to  the  Cleveland  Farm  School. 
Girls  may  be  committed  to  the  House  of  the  Good  Shepherd  or  to  the  State 
Industrial  School  for  Girls.  These  institutions  will  be  described  a  little 
later.  They  receive  many  mentally  defective  children,  sometimes  those  of 
relatively  low  grade,  and,  in  consequence,  the  tasks  for  which  they  were 
created  are  less  efficiently  performed.  This  is  largely  due  to  the  absence  of 
fully  adequate  facilities  in  the  court  for  scientific  mental  diagnosis  but  were 
such  facilities  available  many  children  Would  still  have  to  be  disposed  of 
in  this  way  on  account  of  the  very  inadequate  state  provisions  for  institu- 


Mental  Diseases  and  Deficiency  481 

tional  care  of  the  mentally  defective  and  the  lack  of  a  mental  deficiency  law 
under  which  an  effective  system  of  extra-institutional  supervision  and  guard- 
ianship can  be  constructed. 

When  it  is  apparent  from  the  histories  and  the  results  of  psychiatric  and 
psychological  examinations  that  children  are  mentally  defective  and  require 
institutional  care  the  Judge  of  the  Juvenile  Court  makes  every  effort  to 
secure  admission  to  an  appropriate  institution.  He  can  transfer  the  case  to 
the  Probate  Court  for  commitment,  to  a  state  hospital  (which  is  rarely 
done),  commit  directly  to  the  State  Institution  for  the  Feeble-minded,  the 
State  Hospital  for  Epileptics,  or  to  the  custody  of  the  Board  of  Administra- 
tion for  transfer  to  an  institution  upon  recommendation  of  the  Bureau  of 
Juvenile  Research. 

This  court  needs  a  psychiatric  clinic  to  help  it  deal  with  the  perplexing 
and  enormously  important  problems  in  human  conduct  that  come  before  it. 
Here  are  to  be  observed  the  first  difficulties  that  subnormal  or  psychopathic- 
children  experience  in  making  the  adaptations  that  are  required  for  socially 
acceptable  behavior.  Upon  the  methods  here  employed  for  checking  un- 
desirable adaptations  and  substituting  desirable  ones  depend  not  only  the 
future  happiness  of  children  and  of  the  families  of  which  they  are  members, 
but  the  success  or  failure  that  the  community  will  later  achieve  in  dealing 
with  much  adult  delinquency  and  crime.  ,  The  time  has  long  since  passed 
when  it  was  necessary  to  defend  utilizing  to  the  utmost  in  Children's  Courts 
the  sciences  that  have  to  do  with  the  deep  springs  of  conduct.  Practical 
demonstrations  by  this  time,  extending  over  a  number  of  years,  justify  the 
statement  of  one  Judge  of  a  Juvenile  Court  that  he  would  not  be  willing  to 
continue  his  work  if  deprived  of  the  services  of  his  psychiatric  advisor. 

The  maintenance  of  a  psychiatric  clinic  for  the  Cleveland  Juvenile  Court 
should  constitute  one  of  the  broader  "outpost"  duties  of  the  proposed  City 
Psychopathic  Hospital.  Backed  by  the  resources  of  such  a  hospital,  with  its 
highly  trained  personnel,  ward  service  for  children,  laboratories  and  well 
organized  social  service,  such  a  clinic  in  the  Juvenile  Court  would  be  much 
more  useful  than  a  small  clinic  acting  independently. 

Detention  Home — An  indispensable  adjunct  to  every  Children's  Court 
is  a  place  where  children  may  be  safely  detained  while  their  cases  are  under 
investigation  or  while  they  are  awaiting  disposition.  In  Cleveland  this  is 
provided  by  the  Detention  Home,  consisting  of  offices  in  a  remodelled  frame 
dwelling  and  quarters  for  the  children  in  a  fireproof  addition.  The  building- 
is  sanitary,  well  designed  for  the  purpose  that  it  serves  and  regarded  as  very 
satisfactory.  Recreation  rooms  in  the  building  and  a  playground  outside 
have  been  provided.  Adjoining  property  has  been  purchased  so  that  depend- 
ent children  may  be  placed  in  a  building  entirely  separate  from  that  in  which 
delinquents  are  quartered.  Changes  must  be  made  in  this  structure  to 
eliminate  a  fire  hazard  but,  even  with  present  facilities,  dependent  and 
delinquent  children  are  provided  for  separately.  The  total  capacity  of  the 
Detention  Home  is  135.  The  usual  population  is  from  100  to  140.  On 
April  1,  1920,  there  were  ninety -nine  present — sixty-nine  boys  and  thirty 


482  Hospital  and  Health  Survey 

girls.  On  that  date  fourteen  boys  and  six  girls  selected  at  random  were 
carefully  examined  mentally.  Nine,  or  40  per  cent  were  found  to  be  men- 
tally defective. 

The  stay  of  the  children  in  the  Detention  Home  is  necessarily  short  as 
they  are  detained  only  while  their  cases  are  pending.  During  this  brief 
period,  however,  education  is  not  neglected.  Boys  attend  the  Boys'  School, 
close  at  hand,  and  girls  receive  instruction  in  the  home  building.  Academic 
subjects  are  taught  and  some  instruction  given  in  domestic  science  and 
manual  training.  There  are  many  evidences  of  kindness,  sympathy  and 
understanding  on  the  part  of  those  responsible  for  the  operation  of  this 
institution. 

When  a  psychiatric  clinic  is  included  in  the  resources  that  the  Juvenile 
Court  has  at  its  disposal,  the  observation  of  special  cases  in  the  Detention 
Home  will  yield  very  important  psychiatric  information. 


Correctional  Agencies 

The  public  correctional  agencies  of  the  state  were  not  examined  in  this 
survey.  For  children  there  are  the  Girls'  Industrial  School  near  Delaware 
and  the  Boys'  Industrial  School  near  Lancaster.  The  Boys'  Industrial  School 
receives  boys  between  the  ages  of  ten  and  eighteen.  They  may  be  retained 
until  the  age  of  twenty-one.  The  Girls'  Industrial  School  was  established  in 
1869  for  "the  instruction  and  reformation  of  incorrigible  girls  between  the 
ages  of  nine  and  eighteen. "  A  report  published  by  the  Bureau  of  Juvenile 
Research  in  1915  showed  that  more  than  50  per  cent  of  1,000  children  ex- 
amined in  the  two  schools  were  mentally  defective. 

House  of  Correction — The  House  of  Correction,  situated  on  the 
same  reservation  at  Warrensville  as  the  City  Infirmary,  the  Tuberculosis 
Sanatorium  and  the  Girls'  Home,  is  a  modern  building,  clean,  sanitary  and 
well  conducted.  All  Courts,  except  the  Juvenile  Court,  commit  to  the 
House  of  Correction.  Only  misdemeanants  are  received,  the  maxi- 
mum sentence  being  one  year's  imprisonment  and  a  fine  of  $500.  Prisoners 
may  be  paroled  at  any  time  in  the  discretion  of  the  Director  of  Public  Wel- 
fare. During  1918,  4,986  men  and  695  women  were  admitted.  In  the  year 
following  the  male  admissions  fell  to  3,002  and  the  female  admissions  to  408. 
The  greatest  number  in  the  institution  at  any  time  was  662  men  and  88 
women  in  1918  and  748  men  and  81  women  in  1919.  It  is  seen  that  the 
greatest  decrease  in  1919  was  in  prisoners  serving  the  shortest  terms.  This 
is  ascribed  chiefly  to  prohibition.  During  the  last  six  months  it  has  been 
still  greater  than  previously  and  the  average  daily  population  is  less  than 
forty.  On  the  women's  side  with  a  capacity  of  150  the  average  daily  popu- 
lation in  1919  was  only  fifty-two.  The  best  use  to  make  of  the  vacant  parts 
of  the  building  is  receiving  much  thought.  There  are  many  agencies  that 
could  make  use  of  increased  institutional  facilities  but  few  care  to  use  a  penal 
institution.  It  has  been  suggested  that  it  be  used  as  a  convalescent  hospital 
for  patients  from  the  City  Hospital,  for  an  isolation  hospital  for 
venereal    patients,    and    for    the    care    of   feeble-minded    women    of   child- 


Mental  Diseases  and  Deficiency  483 


bearing  age  pending  proper  provision  by  the  state.  The  desirability 
of  the  city  making  provision  for  the  mentally  defective  is  open  to 
serious  question.  However  temporary  these  provisions  may  be  intended 
to  be,  experience  shows  that  they  are  exceedingly  likely  to  be  permanent. 
There  is  general  agreement  that  the  institutional  care  of  the  mentally  de- 
fective is  the  function  of  the  state.  Granting  that  some  increased  provisions 
by  the  state  will  soon  be  made  available,  it  is  certain  that  if  Cleveland  makes 
the  provisions  at  the  House  of  Correction  suggested,  the  new  beds  in  state 
institutions  will  be  used  first  for  residents  of  other  localities  in  which  it  may 
be  assumed  that  the  pressure  for  room  for  such  patients  is  quite  as  marked  as 
in  Cleveland.  By  far  the  wisest  thing  to  do  during  the  period  of  waiting 
for  the  state  to  meet  its  deficit  is  to  increase  the  facilities  for  community 
supervision  and  guardianship.  If  as  much  progress  in  this  direction  is  made 
as  the  experience  of  other  communities  shows  is  possible,  the  need  for  insti- 
tutional provisions  may  be  found  to  be  less  than  it  would  be  if  1,000  or  2,000 
additional  beds  in  state  institutions  were  suddenly  made  available  at  the 
present  time. 

Some  of  the  statistics  obtained  regarding  prisoners  admitted  to  the 
House  of  Correction  suggest  a  relatively  high  proportion  of  mentally  defec- 
tive individuals.  The  changing  character  of  the  population  resulting  from 
the  great  decrease  in  the  number  of  prisoners  convicted  of  intoxication  and 
minor  offenses  growing  out  of  alcoholism  is  indicated  by  the  marked  differ- 
ence in  the  percentage  of  illiterates  between  1918  and  1919.  During  1918, 
when  there  were  1,123  admissions  for  intoxication — or  20  per  cent  of  all 
admissions — the  proportion  of  illiterates  was  8.3  per  cent.  During  1919  only 
471  prisoners  were  committed  for  intoxication,  constituting  14  per  cent  of 
the  total  number  of  admissions.  In  that  year  the  proportion  of  illiterates 
was  16.9  per  cent.  It  is  evident  that  formerly  alcohol  played  an  important 
part  in  the  failure  to  make  social  adjustments  which  brought  people  to  the 
House  of  Correction  but  that,  in  the  absence  of  this  causative  agent,  crime 
and  delinquency  are  committed  by  persons  less  typical  of  the  entire  com- 
munity. In  such  a  group  the  feeble-minded  will  always  be  found  in  the 
highest  proportion.  This  bears  out  the  experience  of  other  communities 
which  have  seen  their  problems  of  crime  and  delinquency  chan^estrikingly 
during  the  last  ten  years,  first  by  the  wider  use  of  probation  and  ffc-ole  which 
greatly  shortens  the  terms  of  normal-minded  prisoners  without  affecting  in 
the  same  degree  the  mentally  defective,  and  more  recently  by  prohibition 
which  lessens  the  number  of  accidental  criminals  and  delinquents  but  does 
not  affect  in  such  a  marked  manner  those  whose  offenses  are  due  to  more 
deeply  seated  causes  of  unacceptable  social  behavior. 

Forty-seven  men  and  seven  women,  taken  at  random  and  representing 
presumably  the  average  population  of  the  House  of  Correction,  were  examined 
mentally.  Of  this  number  five  were  found  to  have  definite  mental  diseases 
and  twenty  to  be  mentally  defective.  Here,  then,  as  in  other  types  of  insti- 
tutions for  the  socially  inadequate,  we  find  a  heavy  proportion  of  those  whose 
difficulties  are  due  to  mental  defect  or  disease.  It  is  obvious  that  it  is  use- 
less to  expect  an  institution  of  this  sort,  however  efficiently  administered,  to 
accomplish  much  with  individuals  who  have  severe  and  often  permanent 


484  Hospital  and  Health  Survey 

defects  of  the  brain.  Although  there  are  no  routine  psychiatric  examina- 
tions to  determine  the  real  nature  of  the  mass  of  asocial  humanity  dealt  with 
in  this  institution,  there  is  a  rough  and  ready  practical  recognition  of  the 
existence  of  an  important  problem  in  mental  deficiency  by  those  who  actually 
come  into  contact  with  the  prisoners.  Many  of  the  features  in  the  daily 
routine  of  institutional  life  which  experience  has  shown  to  be  desirable  indi- 
cate quite  clearly  that  the  limited  capacity  of  the  feeble-minded  has  been 
taken  into  account  in  the  development. 

Farm  School — Near  Hudson,  twenty-three  miles  from  Cleveland  on 
electric  and  steam  railways,  is  the  Cleveland  Farm  School.  After  some  early 
difficulties  this  school  got  under  way  in  1903.  It  is  conducted  by  the  Depart- 
ment of  Public  Welfare.  All  commitments  are  made  through  the  Juvenile 
Court.  Usually  there  is  a  waiting  list  (twenty  at  present)  and  it  is  necessary 
to  hold  boys  who  have  been  committed  to  the  Farm  School  at  the  Detention 
Home  (page  481)  where  they  remain  under  the  jurisdiction  of  the  Court  and 
attend  the  Boys'  School  nearby  (page  486).  When  children  are  admitted  to 
the  Farm  School  from  the  Detention  Home  all  information  that  has  been 
gathered  regarding  them  is  sent  at  the  same  time. 

The  school  is  a  cottage  institution,  each  cottage  being  under  the  charge 
of  a  master  and  a  matron.  The  eight  frame  cottages  were  designed  to  accom- 
modate 120  boys,  but  the  present  census  is  150.  The  superintendent,  who 
was  formerly  a  teacher  in  the  East  High  School,  is  energetic  and  progressive 
but  is  much  hampered  by  insufficient  funds.  Academic  instruction  is  under 
the  direction  of  the  Cleveland  Board  of  Education.  Four  teachers,  three 
men  and  one  woman,  are  employed  at  an  average  salary  of  $1,480  a  year. 
School  work  continues  throughout  the  year.  Manual  training  and'  country 
sports  provide  work  and  recreation.  It  is  said  that  it  is  possible  to  get  on 
successfully  with  much  more  liberty  than  is  feasible  at  the  State  Industrial 
School  at  Lancaster  and  that  the  results  have  been  exceedingly  good.  At 
first  it  was  thought  that  a  short  period  of  institutional  life  and  a  long  parole 
would  prove  the  best  method  but  recently  the  period  of  institutional  care 
has  been  lengthened  with  much  better  results. 

In  connection  with  the  Farm  School  is  a  well  organized  Placement  De- 
partment which  not  only  places  boys  from  this  school  but  from  the  State 
Industrial  School  at  Lancaster.  Principals  of  schools  have  been  instructed 
not  to  receive  boys  directly  from  either  institution  but  to  refer  them  to  the 
Placement  Department.  The  follow-up  work  thus  provided  for  is  carried  on 
as  efficiently  as  the  funds  and  personnel  available  permit. 

The  Girls'  Home — This  is  a  wooden  structure  with  a  capacity  of  thirty- 
nine  which  is  usually  exceeded.  An  effort  is  made  to  receive  only  delinquent 
girls  who  are  not  sexually  immoral.  The  matron  and  the  teacher,  who  are 
doing  notable  work,  are  aware  of  the  importance  of  detecting  feeble-minded 
and  psychopathic  girls  and  modifying  their  training  in  accordance  with  their 
special  needs,  but  are  without  the  expert  advice  which  is  so  essential.  The 
practical  type  of  instruction  carried  on  is  very  well  suited  to  the  require- 


Mental  Diseases  and  Deficiency  485 


ments  of  subnormal  types  if  a  careful  mental  examination  were  possible  in 
order  to  indicate  the  kind  of  training  most  likely  to  be  useful  in  each  case. 
The  examinations  made  indicate  that  such  girls  constitute  about  20  per 
cent  of  those  received.  In  this  home,  as  in  most  such  places  for  the  tempo- 
rary care  of  young  people  who  are  delinquent  or  dependent,  the  mentally 
defective  require  an  undue  amount  of  the  attention  from  those  in  charge,  and 
they  do  not  receive  a  corresponding  amount  of  benefit.  Such  institutions 
feel  the  full  weight  of  the  state's  failure  to  provide  adequately  for  the 
mentally  defective.  If  the  extra  work,  anxiety  and  interference  with  broad 
aims  for  individual  reconstruction  which  is  due  to  the  burden  of  feebleminded- 
ness in  such  homes,  refuges  and  shelters  throughout  the  state,  were  fully 
known  the  legislature  could  not  fail  to  be  moved  to  make  the  provisions 
that  have  been  promised  so  long. 

House  of  Good  Shepherd — The  House  of  the  Good  Shepherd  is  situated 
on  Carnegie  Avenue  at  30th  Street  and  is  one  of  the  notable  institutions  of 
the  same  name  to  be  found  in  many  large  cities  throughout  the  world.  The 
girls  received  are  divided  into  three  groups.  The  group  composed  of  delin- 
quent girls  committed  by  the  Juvenile  Court  is  the  largest  group,  and  when 
the  institution  was  visited,  numbered  120.  Dependent  girls  form  the  next 
largest  group  and  numbered  sixty -five.  There  were  forty  girls  in  the  "Mag- 
dalene" group. 

The  institution  is  conducted  in  accordance  with  a  very  definite  point  of 
view  regarding  the  problems  presented.  It  is  felt  that  the  atmosphere  of 
religious  influence  and  kindness  which  has  been  created  by  the  devotion  of 
the  Sisters  who  conduct  the  institution  can  be  depended  upon  to  bring  about 
better  living  and,  in  order  to  intensify  the  impression  upon  the  minds  of  the 
girls  that  their  entrance  into  the  home  is  the  fresh  starting  point,  each  girl 
receives  a  new  and  fictitious  name  by  which  she  is  known  to  everyone.  Of 
course  this  renders  it  impossible  to  trace  individuals  through  previous  de- 
linquent experiences  or  to  establish  their  school  records.  The  past  histories 
of  the  girls  are  never  discussed.  There  is  great  reluctance  to  have  the  diag- 
nosis of  mental  deficiency  or  psychopathic  conditions  made  and  the  children 
transferred  to  special  institutions  unless  serious  disorders  of  conduct  makes 
such  a  step  necessary.  This  is  due  to  the  intense  devotion  to  their  tasks 
which  the  Sisters  have  and  a  belief  that  no  effort  should  be  spared  to  bring 
about  reformation  even  in  those  who  seem  the  least  promising.  It  results 
not  infrequently  in  achievements  in  individual  cases  that  would  not  be  thought 
possible  by  those  whose  early  and  only  recourse  in  difficult  cases  is  the  insti- 
stitution  for  the  mentally  defective  and  it  represents  the  literal  carrying  out 
of  a  very  honest  and  deep-seated  conviction  as  to  the  basic  factors  in  immoral 
conduct. 

Twenty  of  the  delinquent  girls  were  examined  mentally.  One  was  found  to 
be  suffering  from  a  psychopathic  condition  and  eight  were  mentally  defective. 
If  the  same  proportion  exists  in  this  entire  group  the  percentage  of  mentally 
defective  girls  is  forty-five.  Thirteen  of  the  dependent  girls  were  examined 
of  whom  five  were  found  to  be  mentally  defective  and  one  suffering  from  a 


486  Hospital  and  Health  Survey 

psychopathic  condition.  This  would  indicate  the  same  proportion  in  the 
entire  group  as  in  the  delinquents.  None  in  the  "Magdalene"  group  were 
examined. 

Academic  instruction  is  carried  on  with  training  in  domestic  science, 
especially  laundry  work.  Many  girls  who  have  been  admitted  to  the  home 
have  gone  out  to  live  useful  and  orderly  lives. 

Boys'  School — The  Boys'  School,  situated  on  Clinton  Avenue  at  29th 
Street,  was  organized  in  1876  for  "truant  and  incorrigible  boys."  At  first  it 
was  called  the  "Special  Unclassified  School"  and  the  object  of  its  establish- 
ment was  to  segregate  boys  who  "because  of  immoral  conduct  were  a  detri- 
ment to  work  of  the  regular  classes."  Later  the  present  name  was  adopted. 
For  a  time  the  classes  were  conducted  in  several  different  buildings,  but  in 
1904  they  were  united  in  the  present  building.  There  are  two  sources  of 
admission — the  city  Board  of  Education  through  a  certificate  of  the  Assistant 
Superintendent  of  Education,  upon  application  of  the  principal  of  the  school 
which  the  boy  attended,  and  commitment  by  the  Juvenile  Court.  Boys 
sent  from  the  Board  of  Education  are  known  as  "  incorrigibles "  and  are  a 
charge  upon  the  city  while  those  sent  by  the  Juvenile  Court  are  known  as 
"detention  cases"  and  are  a  charge  upon  the  county. 

Upon  admission  to  the  school  each  boy  is  first  studied  by  the  Placement 
Department  of  which  Miss  Claire  Walters  is  the  head.  Miss  Walters  com- 
menced her  work  as  a  teacher  in  the  Boys'  School  in  1902.  Since  1907  she 
has  been  attached  to  the  Juvenile  Court  and  since  1912  has  been  fitting  her- 
self by  summer  study  for  psychological  work.  The  findings  of  the  psycho- 
logical tests  constitute  the  chief  factor  in  the  subsequent  disposition  of  the 
boys.  Those  who  seem  to  be  mentally  defective  are  referred  to  the  psycho- 
logical clinic  of  the  Board  of  Education  for  examination  by  Dr.  Luckey  and 
placement  by  Miss  Steinbach.  If  not  suitable  candidates  for  the  special 
classes  they  are  assigned  to  classes  in  the  Boys'  School  and  observations  upon 
their  conduct  are  carefully  made.  There  are  eight  grades  and  two  classes 
for  the  subnormal.  Besides  the  usual  academic  branches,  manual  training, 
weaving,  printing  and  knitting  are  taught.  The  printing  classes  have  been 
especially  successful,  many  boys  securing  part-time  employment  outside. 
Sale  of  the  products  of  the  manual  training  shops  provides  funds  for  the  pur- 
chase of  materials.  There  are  also  night  classes  and  the  school  term  extends 
throughout  the  year.  Most  of  the  children  from  the  Juvenile  Court  reside 
in  the  school  and  most  of  the  incorrigible  boys  live  at  home. 

There  are  no  psychiatric  examinations  of  the  boys  in  spite  of  the  growing 
body  of  information  that  is  accumulating  regarding  the  relation  that  exists 
between  certain  psychopathic  conditions  and  disorders  of  conduct  in  chil- 
dren. Here  is  another  favorable  place  for  an  "outpost"  of  the  City  Psy- 
chopathic Hospital  when  it  is  established. 


Mental  Diseases  and  Deficiency  487 

Other  Homes 

Sixteen  orphanages  and  other  homes  conducted  by  private  agencies  were 
visited.  Although  maintained  chiefly  for  dependent  children  all  have  their 
problems  of  delinquency  with  which  to  deah 

In  all  the  institutions  for  delinquents  visited  the  total  census  on  the  dates 
that  visits  were  made  was  1,975.  |Of  this  number  375  children,  chosen  for  the 
most  part  at  random,  were  examined  mentally  by  the  psychiatrists  and 
psychologists  associated  with  the  Survey.  Fifteen  of  all  those  examined 
were  found  to  have  some  psychopathic  condition  and  fifty-six  to  be  mentally 
defective.  If  the  proportion  of  psychopathic  and  mentally  defective  chil- 
dren was  the  same  in  the  total  population  of  these  institutions  there  were 
not  less  than  374  individuals  who  presented  a  demonstrable  mental  disorder 
or  a  definite  mentally  defective  condition,  by  far  the  greater  proportion  of 
whom  could  have  been  cared  for  in  special  state  institutions  with  advantage 
to  themselves  and  to  the  community.  It  is  doubtful  whether  any  other 
institutions  are  as  greatly  impeded  in  their  work  by  the  presence  of  a  large 
component  of  persons  utterly  unsuited  for  the  environment  in  which  they 
live  as  these  homes  and  schools  established  and  maintained  for  the  care  and 
training  of  dependent  and  delinquent  girls  and  boys.  Sometimes  these  insti- 
tutions are  harshly  criticized  for  the  quality  of  their  work,  but  few  people 
stop  to  realize  that  they  are  carrying  a  burden  which  the  state  should  carry, 
and  that  many  if  not  all  the  deficiencies  in  their  work  are  due  to  this,  the  fact 
that  a  large  part  of  all  their  slender  resources  has  to  be  devoted  to  a  task  that 
is  not  primarily  theirs  at  all  and  was  not  in  the  minds  of  those  whose  gener- 
osity made  these  institutions  possible.  It  is  easy  to  say  that  all  mentally 
defective  and  psychopathic  children  could  be  excluded  from  institutions  that 
were  not  intended  for  them,  but  no  one  who  has  seen  the  plight  that  many  of 
these  children  present,  coming  as  they  do  so  often  from  homes  presided 
over  by  feeble-minded  parents,  would  have  the  heart  to  advocate  closing  the 
only  doors  that  are  open  to  them.  But  for  the  patience  and  humanity  of 
those  who  work  day  and  night  with  these  children  the  real  tragedy  of  the 
state's  neglect  to  provide  for  the  mentally  defective  would  be  far  more  appar- 
ent than  it  is.  The  imbecile  girl,  often  with  her  illegitimate  baby,  the  psycho- 
pathic boy  with  gravely  delinquent  traits  that  make  him  an  unsafe  companion 
for  other  children,  the  irritable  epileptic  child,  all  are  taken  into  these  homes 
and  cared  for  in  spite  of  the  fact  that  their  presence  interferes  seriously  with 
work  that  would  be  difficult  enough  under  most  favorable  conditions  and 
that  it  is  well  known  to  the  authorities  of  the  home  that  little  or  nothing  will 
be  accomplished  by  methods  that  have  been  carefully  devised  for  the  train- 
ing or  social  rehabilitation  of  the  normal  minded. 

There  are  but  two  remedies  for  this  condition  which  is  to  be  seen  in  the 
institutions  for  dependents  and  delinquents  in  nearly  all  large  American  cities. 
The  first  is  careful  psychological  and  psychiatric  examination  and  classifica- 
tion of  all  applicants  for  admission  and  the  second  is  an  adequate  system  of 
state  institutional  care  and  community  supervision  for  those  who  are  rendered 
socially  inadequate  on  account  of  mental  deficiency  or  unstable  mental  make- 
up. 


488  Hospital  and  Health  Survey 

Mentally  Atypical  Children  in  tne  Schools 
Special  Classes  for  the  Mentally  Defective 

CLEVELAND  has  provided  instruction  in  special  classes  for  the  men- 
tally defective  since  1905,  when  four  classes  were  organized  for  "defec- 
tive pupils,"  it  being  recognized  that  the  provision  for  "backward 
children"  made  in  1893  was  not  suitable  for  those  with  more  serious  men- 
tal defects.  At  the  present  time  such  classes  are  well  conducted  under  the 
general  supervision  of  Miss  Charlotte  Steinbach  who  has  had  special  train- 
ing for  this  work.  The  psychological  examinations  are  conducted  by  Bertha 
M.  Luckey,  Ph.  D.,  with  the  assistance  of  Miss  Florence  Durst,  a  specially 
trained  teacher. 

Some  of  the  special  class  centers  are  poorly  provided  for.  They  have 
only  one  or  two  rooms  while  others  have  four  or  five  rooms  which  permit 
satisfactory  classification.  Each  class  has  from  12  to  15  pupils.  There  are 
about  1,000  children  in  all  the  special  classes.  This  constitutes  somewhat 
less  than  one  per  cent  of  the  total  school  population.*  Cooperation  between 
the  special  class  teachers  and  the  grade  teachers  is  good.  When  a  child 
appears  to  the  grade  teacher  to  be  atypical,  incapable  of  doing  the  regular 
work  and  is  being  passed  for  promotion,  the  child  is  reported  to  the  principal 
of  the  school  and  the  name  of  the  child  sent  to  Miss  Steinbach's  office.  The 
names  come  in  at  intervals,  in  long  lists.  Children  are  also  referred  by  the 
Juvenile  Court,  the  Humane  Society  and  other  welfare  organizations,  paro- 
chial schools  and  parents.  These  children  are  referred  to  Dr.  Luckey,  who 
conducts  a  careful  psychological  examination,  usually  in  the  dispensary  of 
the  school  which  the  child  attends.  Children  in  whom  a  diagnosis  is  not 
possible  with  such  an  examination  are  brought  to  the  office  for  special  study. 
In  such  cases  a  carefully  prepared  history  blank  is  sent  to  the  school  to  be 
filled  with  all  the  information  that  can  be  obtained  by  a  personal  investiga- 
tion. The  careers  of  these  children  are  followed  as  thoroughly  as  possible. 
In  this  the  "Clearing  House"  in  the  building  of  the  Associated  Charities, 
under  the  Welfare  Federation,  is  able  to  render  valuable  assistance  by  report- 
ing, usually  within  three  days,  the  names  of  other  members  of  the  family 
who  have  received  relief  or  have  been  dealt  with  by  the  courts.  During  last 
year  about  1,400  of  the  2,916  children  examined  were  found  to  be  mentally 
defective.  Investigation  of  these  cases,  through  the  Clearing  House,  showed 
that  members  of  the  families  of  the  mentally  defective  children  had  Juvenile 
Court  records  in  466  instances.  In  173  of  these  cases  there  had  been  two  or 
more  appearances  in  the  Juvenile  Court. 

Some  of  the  children  who  are  of  very  low  grade  mentally  are  sent  to 
appropriate  institutions,  when  vacancies  exist,  without  being  placed  in  special 
classes  at  all.  About  half  of  all  the  children  examined  are  thought  to  be 
simply  cases  of  slow  development  or  children  in  whom  other  causes  than 
mental  deficiency  are  responsible  for  failure  in  school.  The  rest  are  assigned 
to  the  special  classes  that  seem  to  fit  their  requirements  best.  It  is  well  un- 
derstood that  a  single  examination  is  not  always  conclusive  and  the  lack  of 

•Division  of  Health  Report,  March,   1920:    public  schools,   108,000;    parochial  schools,  36,197. 


Mental  Diseases  and  Deficiency  489 

time  for  making  repeated  examinations  is  much  regretted.  Careful  observa- 
tion in  the  special  classes  by  experienced  teachers  compensates  in  part  for 
this  defect.  An  effort  is  made  to  have  it  generally  understood  that  admission 
to  these  classes  does  not  necessarily  imply  a  positive  diagnosis  of  mental 
deficiency. 

The  teachers  of  the  special  classes  are  enthusiastic  over  their  work  and 
feel  convinced  that  they  are  accomplishing  something  of  real  value.  Some 
of  the  principals  are  a  little  out  of  sympathy  with  the  special  classes  and 
express  the  opinion  that  more  children  who  are  "simply  backward"  should 
remain  in  the  regular  classes,  even  though  larger  and  older  than  their  class- 
mates and  that,  for  the  others,  the  special  classes  are  an  inadequate  substitute 
for  permanent  institutional  care.  The  general  impression  in  visiting  the 
special  classes  is  that  there  are  many  defective  children  in  them  who  should 
be  in  state  institutions  and  that  their  removal  would  enable  the  special  classes 
to  do  their  work  with  others  more  successfully.  In  the  absence  of  proper 
state  facilities,  however,  no  one  would  seriously  recommend  that  such  chil- 
dren be  excluded  from  the  special  classes.  When  more  adequate  state  pro- 
visions exist  and  more  defective  children  can  be  admitted  to  proper  institu- 
tions, at  least  for  a  period  of  training,  the  classes  will  undoubtedly  do  better 
work  and  have  more  success  in  their  highly  important  task  of  fitting  the  less 
defective  children  to  take  a  useful  part  in  the  life  of  the  general  community 
with  their  defect  in  intelligence  partly  compensated  for  by  having  learned 
to  do  skillfully  a  few  simple  kinds  of  work  for  which  there  is  a  demand. 

The  salaries  of  the  teachers  in  the  special  classes  are  the  same  as  those  of 
grade  teachers,  with  the  exception  of  head  teachers  who  are  responsible  for 
the  work  of  several  others.  These  receive  from  $50  to  $100  a  year  additional. 
At  least  ten  of  the  special  class  teachers  are  on  the  regular  substitute  list  and 
receive  from  $4.20  to  $6.00  a  day  for  their  services,  which  is  less  than  that 
received  by  grade  teachers.  The  entire  cost  of  the  special  classes  during  the 
year  ending  September,  1919,  was  $71,989.70  for  teachers'  salaries  and 
$106.33  for  supplies.  It  is  doubtful  whether  any  educational  activity  of 
the  city  yielded  larger  returns  for  the  money  expended. 

More  special  classes,  extra  pay  for  teachers  and  better  classification  at 
special  class  centers  are  needed.  In  addition,  more  complete  diagnostic 
facilities  should  be  supplied.  Although  the  schools  have  been  fortunate  in 
securing  the  services  of  so  well  trained  a  psychologist  as  Dr.  Luckey,  it  must 
not  be  forgotten  that  more  than  a  psychological  examination  and  social  in- 
vestigation is  needed  to  deal  satisfactorily  with  the  complex  problems  pre- 
sented by  a  child  whose  mental  development  is  defective  or  retarded.  These 
conditions  depend  upon  brain  defects  but  not  usually  upon  this  cause  alone 
for  there  are  many  closely  related  changes  in  the  body  as  a  whole  and  in  other 
organs  which  have  a  great  deal  to  do  with  both  the  rate  of  mental  develop- 
ment and  the  degree  to  which  it  may  progress.  The  assignment  of  a  child 
to  a  special  class  is  an  event  of  great  importance  in  the  life  of  the  child  and 
of  no  little  importance  to  the  community.  The  examinations  that  precede 
such  a  step  should  be  conducted  in  a  clinic  equipped  to  deal  with  both  mental 
and  physical  issues.  The  great  importance  of  disorders  of  the  "ductless 
glands"  (thyroid,  thymus,  pituitary,  testicles  and  ovaries)  makes  it  essential 


-tOO  Hospital  and  Health  Survey 

that  a  complete  physical  study  should  play  a  large  part  in  such  an  examina- 
tion. The  fatalistic  attitude  too  prevalent  toward  all  mental  defects  has 
excluded  many  a  child  from  treatment  which  might  have  materially  modified 
the  mental  and  social  picture  presented  upon  a  superficial  investigation.  A 
thorough-going  study  of  each  child,  from  a  psychiatric  as  well  as  a  psycho- 
logical point  of  view,  in  which  are  considered  the  child's  personality,  his 
special  abilities  and  interests  and  the  possibility  of  psychotic  or  psycho- 
neurotic trends  is  the  only  basis  upon  which  future  mental  health  and  limits 
of  adaptability  to  a  social  environment  can  be  judged  in  an  individual  still 
in  the  developmental  stage.  Such  a  complete  study  is  the  function  of  the 
psychiatric  clinic. 

Work  Permits  for  the  Mentally  Defective 

The  truancy  law  of  Ohio  provides  that  boys  of  such  subnormal  mental 
capacity  that  they  are  unable  to  get  past  the  sixth  grade  may  receive  special 
permission  to  go  to  work  upon  attaining  fifteen  years  of  age,  and  girls  of  six- 
teen, having  passed  the  seventh  grade  may  also  receive  permission.  At  six- 
teen any  boy  or  girl  may  leave  school.  Boys  of  sixteen  may  go  to  work  with- 
out permits,  but  girls  of  normal  mentality  who  have  not  passed  the  seventh 
grade  cannot  have  permission  to  work  in  factories  until  eighteen.  A  mentally 
deficient  girl  may  have  a  work  certificate  before  eighteen. 

It  is  believed  that  the  law  requiring  school  attendance  should  be  more 
flexible  in  the  case  of  mentally  defective  children.  It  should  give  the  school 
enough  power  to  hold  the  child  when  advisable  in  individual  cases  or  to  recom- 
mend that  children  be  allowed  to  leave  before  they  have  completed  the 
attendance  now  required.  Often  defective  children  leave  school  too  soon, 
when  the  teachers  feel  that  they  have  just  reached  the  point  where  something 
can  be  done  for  them.  It  is  suggested  that  in  cases  where  subnormal  children 
are  not  able  to  receive  benefit  from  academic  instruction  and  are  approaching 
the  age  at  which  they  can  receive  work  permits,  they  should  receive  technical 
training  in  a  school  or  shop,  or  in  domestic  economy,  where,  working  under 
the  supervision  of  expert  teachers  they  can  gain  the  knowledge  and  skill 
that  will  be  helpful  to  them  in  securing  and  maintaining  employment  whicli 
will  command  a  living  wage.  In  this  way  the  fundamental  and  non- 
remediable  mental  defect  may  be  compensated  for  by  intelligently  directed 
training. 

It  should,  however,  be  kept  in  mind  that  if  the  equipment  of  the  shop  or 
school  is  unusual  or  out  of  date  and  instruction  is  given  only  with  such 
apparatus,  re-education  may  be  necessary  when  the  boy  or  girl  takes  up 
employment. 

Work  permits  are  issued  by  the  truant  officer  and  the  subnormal  child's 
mental  age  is  recorded  on  the  card.  Some  people  feel  that  this  handicaps  the 
child  in  obtaining  advantageous  employment,  but  most  of  those  concerned 
believe  that  the  mental  age  should  be  so  recorded  as  the  card  is  not  widely 
displayed  but  is  filed  with  the  employer  and  knowing  the  child's  limitations 
he  can  protect  the  employe  and  himself.     As  a  matter  of  fact  the  feeble- 


Mental  Diseases  and  Deficiency  491 

minded  easily  secure  employment  and  sometimes  receive  very  good  wages. 
Many  anecdotes  are  told,  one  concerning  a  seventeen  year  old  boy  whose 
"mental  age"  was  six  years,  earning  $4.20  per  day  cleaning  cork  in  a  factory. 
He  was  taught  by  a  substitute  teacher  who  received  exactly  the  same  amount 
for  her  services. 

A  review  of  permits  issued  during  a  recent  period  of  six  months  showed 
'that  8.6  per  cent  of  the  boys  and  4.8  per  cent  of  the  girls  were  definitely 
diagnosed  as  feeble-minded  and  had  their  mental  ages  recorded  upon  their 
work  permit  cards. 

The  following  tables,  prepared  by  Miss  F.  V.  Ball,  show  in  detail  the  in- 
formation contained  in  the  health  records  of  these  children  and  an  analysis 
of  the  industries  in  which  those  who  were  working  were  engaged.  The  kinds 
of  work  in  which  they  were  occupied  do  not  differ  materially  from  those  in 
which  all  working  children  are  engaged. 


Hospital  and  Health  Survey 


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494  Hospital  and  Health  Survey 

Special  Types  of  Atypical  Children 

Unusually  Bright  Children — By  means  of  group  psychological  tests, 
supplemented  by  individual  tests,  a  number  of  children  classified  as  "unusu- 
ally bright"  have  been  picked  out  and  the  school  authorities  have  formed 
some  special  classes  and  devised  methods  of  giving  these  children  special 
work.  A  physical  examination  is  made  of  these  children  but  no  psychiatric 
examination.  So  important  is  the  latter  in  determining  whether  or  not  a 
child  shall  be  placed  in  this  group  that,  in  the  opinion  of  the  writer,  the  harm 
likely  to  result  to  unstable  individuals  if  purely  psychological  tests  are  em- 
ployed will  offset  the  good  that  comes  to  others  if  the  experiment  is  continued 
without  such  aid.  It  is  in  this  group  that  some  of  the  graver  psychiatric 
problems  are  often  found.  An  ordinary  physical  examination  in  such  cases 
is  far  from  conclusive  and  often  throws  no  light  upon  the  psychiatric  situa- 
tion. Properly  conducted  such  an  experiment  is  certain  to  yield  important 
results.  Much  has  already  been  done  for  these  children  whose  needs  have 
so  long  been  overlooked.  Often  astonishing  progress  is  made  in  the  special 
classes  for  the  "unusually  bright."  Handicraft  and  domestic  science  play 
a  large  part.  Folk  dancing  and  various  games  fill  part  of  the  time.  A  model 
store  is  conducted  with  great  success.  As  there  is  only  a  "four-period  day," 
some  of  the  children  work  after  hours.  It  is,  however,  a  field  to  be  entered 
only  with  full  appreciation  of  the  complex  factors  with  which  it  will  be  neces- 
sary to  deal. 

Psychopathic  Children — Cleveland  has  not  yet  been  able  to  give  spe- 
cial attention  to  psychopathic  children  in  the  public  schools.  These  children 
usually  possess  normal  intelligence  but  have  volitional  or  emotional  diffi- 
culties or  psychoneurotic  trends  that  interfere  seriously  with  their  family 
and  social  adaptation  in  later  life.  It  is  among  such  children  that  the  fore- 
runners of  grave  mental  disease  are  often  found.  Juvenile  or  adult  delin- 
quency, vagrancy  and  the  development  of  many  asocial  compensations  for 
personality  defects,  make  wrecks  out  of  much  human  material  that  early  in 
life  might  have  been  dealt  with  successfully.  In  such  work  it  is  indispensable 
to  conduct  careful  psychiatric,  psychological  and  social  studies  and  to  co- 
ordinate the  findings,  with  the  element  of  treatment  always  uppermost. 

Speech  Defects — The  essentially  mental  basis  for  speech  defect,  together 
with  the  great  frequency  of  this  condition  among  school  children,  makes 
its  consideration  important.  Since  the  educational  survey  of  Cleveland  in 
1915,  forty-eight  special  classes  have  been  organized  for  treatment  of  speech 
defects.  The  work  was  started  by  fifteen  teachers,  each  teacher  having  three 
classes — a  kindergarten  class,  a  phonetic  class  and  a  stuttering  class.  Some 
are  conducted  in  school  hours  and  some  out  of  school  hours.  At  the  present 
time  there  are  four  teachers  each  teaching  ten  classes  per  week,  each  class 
having  one  hour  of  instruction  per  week.  These  teachers  receive  extra  com- 
pensation of  $200  per  year  for  this  work.  Seventeen  other  teachers  give  in- 
struction outside  school  hours  and  receive  $1.50  per  hour  additional  for  this 
work.  The  work  is  conducted  under  the  general  direction  of  Miss  Williams 
who  devotes  to  it  half  her  time,  for  which  she  receives  $1,880  a  year.  For 
the  other  half  of  her  time  which  is  otherwise  occupied,  she  is  compensated. 


Mental  Diseases  and  Deficiency  49.5 

The  teachers  are  not  particularly  attracted  by  the  increase  in  compensation 
but  are  especially  interested  in  the  work  and  would  prefer  to  do  it  exclusively. 
Since  this  work  has  been  going  on  teachers  in  the  school  have  become  more 
watchful  for  speech  defects  and  recognize  them  more  quickly.  If  teachers 
were  available,  the  number  of  pupils  enrolled  could  be  doubled  at  once.  It 
is  claimed  that  one-third  of  the  kindergarten  children  have  speech  defects 
(lisping  most  common),  and  it  is  hoped  finally  to  give  each  kindergarten 
class  teacher  some  training  for  speech  instruction.  A  good  deal  of  research 
concerning  the  essential  elements  in  difficulty  in  speech  and  the  basic  facts 
underlying  plans  of  treatment  has  recently  been  carried  on.  Much  excel- 
lent work  in  treatment  has  already  been  done,  but  an  important  fact 
often  overlooked  in  speech  classes  is  the  psychoneurotic  basis  for  the  condi- 
tion in  many  cases.  Without  correcting  the  handicaps  found  in  the  psycho- 
neurotic child,  little  in  the  way  of  permanent  results  are  to  be  expected.  If 
the  subject  had  been  taken  up  from  a  psychiatric  approach  this  would  have 
been  readily  comprehended.  It  is  important  that  this  factor  receive  atten- 
tion or  else  much  time  and  money  will  be  used  in  attaining  temporary  results. 


After-care  and  Supervision 

Too  often  attention  is  fixed  upon  the  phase  of  the  lives  of  mentally  de- 
fective children  that  is  passed  in  school  without  realizing  that  in  the  more 
serious  affairs  of  adult  life  the  mental  defect  will  persist  but  the  protection 
of  the  special  class  will  not  be  present.  Many  a  teacher  sees  the  end  of  the 
period  of  school  life  approach  for  her  charges,  especially  the  girls,  with  dread. 
The  transition  is  often  dramatically  sudden.  One  day  the  defective  child  is 
in  an  environment  especially  created  for  her  safety  and  protection,  watched 
over  and  guided  by  those  who  well  understand  the  limitations  of  the  mind 
arrested  in  its  development.  On  the  following  day  this  individual  with  a 
child's  mind  in  a  woman's  body  goes  into  a  world  which  knows  nothing  of 
"mental  age"  or  "limited  responsibility"  and  has  inexorable  standards  of 
conduct  which  do  not  take  such  factors  into  consideration. 

Thanks  to  the  practical  instruction  given  in  the  special  classes,  such  chil- 
dren are  often  better  fitted  than  some  of  their  normal  minded  schoolmates  to 
earn  their  living  at  simple  work  and  have  had  habits  of  industry  developed 
by  the  careful  training  that  they  have  received.  Nevertheless  they  have 
still  only  the  judgment  and  control  of  impulses  of  a  child.  In  many  instances 
they  are  handicapped  by  mentally  defective  parents  so  that  those  who  should 
prove  their  protectors  are  but  an  additional  handicap  to  them. 

There  is  urgent  need  for  a  system  of  community  supervision  that  will 
throw  around  these  grown-up  children  some  of  the  special  protection  that  is 
thrown  around  those  who  are  children  in  years  as  well  as  in  mind.  First,  it 
is  necessary  to  have  a  mental  deficiency  law  that  recognizes  the  need  of  spe- 
cial guardianship  and  provides  a  practical  means  for  supplying  it.  Such  laws, 
modeled  in  most  instances  after  the  "Mental  Deficiency  Act"  of  England 


496  Hospital  and  Health  Survey 

have  been  enacted  in  several  states  and  when  they  exist  and  there  is  an 
efficient  system  of  registration  and  community  supervision  the  work  of  the 
special  class  is  supplemented  in  such  a  way  that  the  feeble-minded  can  and 
do  live  happy,  useful,  harmless  lives  instead  of  inflicting  much  damage  upon 
society  and  being  themselves  harmed  by  a  social  environment  created  for 
people  with  normal  minds. 


Mental  Diseases  and  Deficiency  497 

Welfare  Organizations 

AMONG  the  voluntary  agencies  for  social  work  is  to  be  found  a  very 
keen  appreciation  of  the  part  played  by  mental  factors  in  the  problems 
with  which  they  have  to  deal .  None  see  more  clearly  than  the  workers 
in  these  agencies  the  full  effects  of  the  failure  of  the  state  to  provide 
adequate  facilities  for  caring  for  the  insane,  the  mentally  defective  and  the 
epileptic.  Weary  of  waiting  for  relief  from  this  quarter,  from  which,  how- 
ever, it  must  ultimately  come,  these  agencies  are  devising  for  themselves 
some  makeshift  methods  of  dealing  with  certain  phases  of  abnormal  men- 
tal conditions.  The  general  hospitals  to  which  they  may  refer  all  other 
classes  of  sick  persons  for  help  have  nothing  to  offer  to  those  whose  illness 
is  mental.  Psychiatrists  in  private  practice  give  as  much  time  as  they  can 
afford  to  the  examination  of  special  cases  but  social  workers  are  reluctant 
to  make  use  of  this  means  of  securing  help  except  in  especially  urgent  cases. 
It  is  of  interest  to  review  briefly  what  some  of  the  social  agencies  have  done 
to  provide  means  for  solving  some  of  their  problems. 

American  Red  Cross — This  organization  serves  those  who  have  been  in 
the  naval  and  military  service  of  the  United  States  during  the  recent  war, 
and  their  families.  The  society  has  organized  a  medical  committee  made  up 
of  various  consultants,  including  psychiatrists;  has  employed  a  psychiatrist, 
and,  on  January  9,  1920,  opened  a  neuro-psychiatric  clinic.  The  organiza- 
tion already  has  a  record  of  238  cases  and  believes  that  this  number  will  be 
much  enlarged  when  the  clinic  is  further  developed.  From  January  6th  to 
April  6th,  158  examinations  had  been  made,  the  psychiatrist  personally  ex- 
amining about  100.  Social  workers  bring  the  patients  to  the  clinic  and  re- 
port on  the  family,  economic  and  neighborhood  situation  as  well  as  giving 
attention  to  personal  histories  and  the  facts  which  led  to  the  request  for 
examination.  The  social  workers  receive  instructions  at  the  clinic  which 
assist  them  in  becoming  better  qualified  for  this  special  work.  On  questions 
of  general  physical  health  consultations  are  obtained  at  various  prominent 
hospitals  or  with  members  of  the  mental  committee.  The  Red  Cross  main- 
tains an  Army  and  Navy  Club  where  the  psychiatrist  lives  and  where  several 
quiet  mental  patients  may  be  cared  for. 

Members  of  this  organization  report  that  they  are  much  embarrassed  by 
the  fact  that  the  Government  makes  inadequate  provision  for  ex-soldiers 
with  mental  and  nervous  disorders.  There  are  thirty  in  the  neighborhood 
who  need  hospital  care,  which  at  present  is  unavailable. 

The  Associated  Charities — This  organization  finds  that  with  the  widen- 
ing of  its  field  beyond  the  supplying  of  necessities  of  life  such  as  food,  fuel, 
clothing  and  shelter,  its  work  now  includes  health,  education,  employment, 
recreation  and  spiritual  development,  the  last  having  for  its  objective  the 
development  of  "a  working  philosophy  of  life"  that  will  help  to  make  the 
adjustments  necessary  for  living  in  a  modern  community.  Of  the  2,000 
families  cared  for  by  the  Associated  Charities  less  than  600  receive  material 
help,  the  other  1,400  being  able  to  work  out  their  own  problems  after  receiv- 
ing advice  and  personal  assistance. 


498  Hospital  and  Health  Survey 

In  carrying  out  this  program  a  psychological  approach  to  the  problems  of 
the  individuals  concerned  is,  of  course,  necessary.  A  survey  of  1,960  families 
under  the  care  of  the  organization  during  March,  1920,  disclosed  359  in  which 
abnormal  mental  condition  was  an  important  element  in  the  social  problem 
presented.  In  these  359  families  there  were  574  individuals  listed.  The 
number  of  individuals  is  probably  smaller  than  the  actual  number  because 
the  list  was  made  conservatively,  especially  in  regard  to  the  number  of  indi- 
viduals with  mental  difficulties.  It  is  believed  that  if  a  psychiatric  clinic 
were  available  for  closer  study  of  these  famiKes,  a  larger  number  of  mentally 
abnormal  members  would  be  found.  Among  these  574  individuals,  however, 
46  are  already  in  hospitals  for  the  insane  and  19  in  institutions  for  the  feeble- 
minded. It  was  thought  that  56  more  should  be  in  such  hospitals  and  136 
in  institutions  for  the  feeble-minded.  These  data  are  shown  in  detail  in  the 
following  table. 

FAMILIES  AND  INDIVIDUALS  UNDER  CARE  OF  ASSOCIATED  CHARITIES 
WITH  MENTAL  DISORDERS 

Group  1; — Diagnosed  Cases 

Families  Individuals 

Mental  Diseases  and  Constitutional  Psychopathic  States 88  95 

Mental  Deficiency ..-..        107  148 

Epilepsy... '. 12  12 

Group  2 — Well-defined  Mental  Cases,  but  not  Diagnosed 

Families    Individuals 

Mental  Disorder 29  41 

Mental  Deficiency . 28  76 

Group  3 — Mental  Disorder  or  Mental  Deficiency  Strongly  Suspected,  but 

not  Well-defined 

Families    Individuals 

Mental  Disorder , 41  64 

Mental  Deficiency 54  138 

Total  of  the  three  groups 359  574 

It  is  stated  that  there  is  great  difficulty  in  securing  the  commitment  of 
mental  patients  unless  the  condition  from  which  they  suffer  is  severe  and  that 
uncured  patients  are  too  freely  paroled  from  the  hospitals.  The  commitment 
of  the  feeble-minded  is  extremely  difficult  because  of  the  lack  of  institutional 
space. 

The  association  is  deeply  interested  in  preventive  work  and  the  treatment 
of  cases  in  early  stages  to  avert  further  development  of  mental  disorders. 


Mental  Diseases  and  Deficiency  499 

In  the  absence  of  any  special  provision  for  mental  hygiene  work  it  is  doing 
what  is  possible  by  means  of  its  own  workers. 

Humane  Society — The  Humane  Society  found  that  in  its  work  it  was 
frequently  necessary  to  have  mental  age  and  capacity  of  children  and  adults 
tested,  but  no  local  agency  was  available  to  give  this  assistance.  Such  in- 
formation is  needed  in  order  to  reach  an  opinion  as  to  whether  a  father  can 
take  and  keep  a  position  and  whether  a  mother  is  able  to  maintain  a  home 
and  supervise  and  rear  her  children.  The  information  is  essential  in  order 
to  determine  the  proper  form  of  assistance  in  any  particular  case  and  to  de- 
termine what  disposition  and  care  shall  be  given  to  children.  Help  has  been 
received  irregularly  from  the  workers  of  the  Bureau  of  Juvenile  Research 
located  at  Columbus,  and  the  Humane  Society  had  one  of  its  workers  trained 
to  make  intelligence  tests. 

Welfare  Federation — This  organization  is  most  desirous  of  having 
suitable  provisions  made  for  mental  patients  now  in  the  various  orphanages 
and  other  institutions  in  which  it  is  interested.  The  officers  of  this  organiza- 
tion also  feel  the  need  of  psychiatric  clinics  to  which  they  can  turn  for  help. 

The  Women's  Protective  Association — This  is  a  private  association 
supported  from  the  Community  Fund.  It  is  associated  in  its  work  with  the 
Police  Department,  having  an  office  at  the  central  police  station.  Some 
members  of  the  Association  are  special  investigators  without  power,  but 
carry  this  title  to  facilitate  the  discharge  of  their  duties.  The  Association 
takes  charge  of  girls  and  women,  usually  between  the  age  limits  of  fourteen 
and  twenty.  The  police  often  turn  over  to  them  the  insane  and  obviously 
mentally  defective  girls  whom  they  do  not  wish  to  place  under  arrest,  and 
cases  in  which  there  is  not  enough  evidence  to  go  into  court. 

This  Association  makes  home  investigations  for  the  superintendent  of  the 
institution  for  the  feeble-minded  and  obtains  reports  on  his  parole  cases. 
It  also  makes  investigations  for  the  Probate  Court. 

A  woman  to  be  charged  with  the  offense  of  being  a  common  prostitute 
must  have  been  arrested  before.  The  so-called  "golden  rule"  method  of 
handling  these  cases  is  to  have  the  girl  sign  a  confession  when  arrested, 
promising  to  refrain  from  further  delinquency,  after  which  she  is  given  a 
warning  or  placed  under  the  care  of  the  Protective  Association.  The  Asso- 
ciation maintains  Sterling  House  (described  in  another  section  of  this  report) 
for  the  detention  of  girls  in  their  charge. 

A  prominent  psychiatrist  makes  mental  examinations  on  occasion,  the 
Probate  Court  gives  its  cooperation,  and  Miss  Walters  of  the  Boys'  School 
assists.  Nevertheless,  these  facilities  are  too  limited  to  afford  the  type  of 
help  needed.  Mental  cases  must  be  picked  out  by  laymen  and  referred  for 
examination  afterward.  Recently  it  was  necessary  to  send  two  feeble-minded 
women  to  the  county  workhouse  as  they  could  not  be  kept  in  the  home  on 
account  of  venereal  disease  and  evidently  could  not  be  committed  to  an 
institution  for  the  feeble-minded.  The  probation  officer  of  this  Association 
suspects  that  at  least  75  per  cent  of  those  who  come  under  her  care  are  sub- 
normal  and   that   many   others   are   psychopathic.     The  obviously  feeble- 


500  Hospital  and  Health  Survey 

minded  are  sent  to  the  state  institution  at  Columbus,  but  are  readily  released 
on  parole  at  the  request  of  relatives  or  friends,  because  of  the  crowded  condi- 
tion in  the  institution. 

Mental  Test  Registry  of  the  Associated  Charities — The  Associated 
Charities  maintains  a  mental  test  registry  which  consists  of  a  card  index  of 
the  results  of  the  mental  tests  of  children,  made  by  psychologists  and  psychia- 
trists for  the  Probate  Court,  for  the  Board  of  Education  and  for  the  Juvenile 
Court.  There  are  records  of  9,000  families,  including  frequently  more  than 
one  individual  per  family,  usually  the  children.  The  assembling  of  these 
records  was  begun  in  1914.  The  cost  has  been  moderate  and  the  results  of 
the  work  have  been  of  great  benefit  in  the  administration  of  relief  for  families 
in  which  mental  deficiency  or  disease  was  the  chief  factor  in  family  depend- 
ency. This  registry  has  provided  a  storehouse  of  information  for  research, 
education  and  for  propaganda  purposes. 

Cleveland  supports  the  welfare  agencies  mentioned  above  in  a  liberal 
manner  with  full  appreciation  of  the  part  they  play  in  the  social  life  of  the 
city.  How  much  further  would  every  dollar  contributed  to  their  work  go 
if  their  efforts  to  bring  about  better  individual  and  social  adjustments  could 
receive  the  aid  that  a  careful  mental  study  of  each  individual  gives?  It  is 
certain  that  when  the  proposed  City  Psychopathic  Hospital  comes  into  ex- 
istence and  establishes  its  "outposts"  where  they  may  be  of  the  greatest 
service,  the  first  to  derive  benefit  from  the  new  facilities  will  be  the  welfare 
agencies  which  now  have  to  deal  with  some  of  the  most  complex  human  prob- 
lems without  the  information  regarding  the  deep  springs  that  regulate  the 
conduct  of  the  human  beings  concerned  that  can  be  gained  only  in  the  psychi- 
atric clinic. 


Mental  Diseases  and  Deficiency  501 

Prevention — Mental  Hygiene 

DURING  the  four  months  in  which  this  study  was  in  progress  practi- 
cally every  institution  in  Cleveland  which  deals  with  dependents,  de- 
linquents or  persons  who  for  any  reason  require  special  care  and  super- 
vision by  the  community  was  visited  by  members  of  the  Survey  staff.  Social 
workers,  court  officers,  teachers,  physicians  and  others  whose  work  brings  them 
directly  into  contact  with  the  socially  maladjusted  of  the  city  were  inter- 
viewed repeatedly  and  in  many  instances  their  daily  work  was  closely  observed. 
In  twenty-nine  of  the  institutions  visited  children  and  adults  under  care  re- 
ceived a  careful  mental  examination.  Altogether  these  institutions  had  a  popu- 
lation of  2,978  on  the  days  on  which  they  were  visited  and  541  individuals 
were  personally  examined  by  the  Field  Consultant  or  his  assistants.  Among 
those  examined,  who  in  all  cases  were  taken  at  random  from  the  group  under 
study,  there  were  found  119  persons  who  presented  mental  disorders,  consti- 
tutional psychopathic  states,  mental  deficiency  or  epilepsy  of  such  a  degree 
of  severity  that  institutional  care  was  required.  If  the  same  percentage  ex- 
isted in  the  whole  population  of  the  institutions  visited,  and  there  is  no 
reason  to  believe  that  it  does  not,  there  were  in  Cleveland  at  the  time  the 
survey  was  made  651  mental  patients  receiving  temporary  or  permanent 
care  in  institutions  designed  for  entirely  different  purposes.  In  these  unsuit- 
able institutions  they  were  not  only  constituting  a  serious  drain  upon  the 
institutional  resources  but  were  interfering  with  the  specific  objects  for  which 
the  institutions  were  established  and  conducted,  At  some  time,  the  remote- 
ness of  which  depends  chiefly  upon  the  strength  and  the  insistence  of  the 
demand  made  by  the  people  of  the  state,  adequate  institutional  facilities 
for  these  cases  will  be  provided  but  if,  today,  it  were  possible  to  admit  every- 
one of  them  to  an  appropriate  institution,  a  survey  made  six  months  hence 
would  find  nearly  as  many  others  in  their  places.  The  investigation  made  by 
the  Survey  merely  dipped  into  the  stream  of  unadapted  human  beings 
which  flows  continuously  through  the  schools,  courts  and  institutions  of 
Cleveland,  and  ascertained  the  fact,  already  known  by  many  and  suspected 
by  others,  that  disorders  of  the  central  nervous  system  were  in  very  large 
part  responsible  for  the  volume  of  this  stream.  The  stream  can  be  diverted 
into  other  channels  but  what  can  be  done  to  dry  up  its  source?  Are  mental 
disease  and  mental  deficiency  inevitable  accompaniments  of  the  life  of 
American  communities,  or  can  they  in  any  considerable  measure  be  con- 
trolled? It  is  most  important  that  this  report,  which  of  necessity  is  devoted 
so  largely  to  the  institutional  provisions  for  those  with  mental  disorders  and 
mental  deficiency,  should  not  convey  the  impression  that  we  have  to  do  with 
a  problem  which  can  be  handled  in  different  ways  according  to  the  skill, 
enlightenment  and  resources  that  we  bring  to  bear  upon  it  but  which,  never- 
theless, must  always  continue  to  exist  in  the  same  dimensions.  Mental 
diseases  and  mental  deficiency  are  preventable,  to  a  less  extent  than  the 
infectious  diseases  but  to  a  greater  extent  than  most  of  the  degenerative 
physical  diseases.  It  is  beyond  the  scope  of  the  report  even  to  outline  the 
field  of  mental  hygiene  or  the  practical  measures  of  prevention,  but  it  is  de- 
sirable to  suggest  that  the  agencies  which  deal  with  health,  education  and 
the  care  of  dependents  and  delinquents  in  Cleveland  institute  organized 
efforts  to  bring  about  practical  work  in  mental  hygiene. 


50t2  Hospital  and  Health  Survey 

Much  of  the  prevention  of  mental  diseases  lies  in  other  fields  of  preventive 
medicine.  General  paresis,  which  is  responsible  for  one-fifth  of  all  the  male 
admissions  to  hospitals  for  the  insane,  is  a  manifestation  of  syphilis  and  its 
prevention  lies  in  the  prevention  of  the  primary  disease.  Mental  diseases 
dependent  upon  alcohol  and  drugs  are  prevented  only  by  the  legal  and  social 
measures  which  can  be  directed  against  the  particular  evils  from  which  they 
come.  Much  mental  disease  is  the  result  of  general  physical  illness  and  its 
prevention  depends  upon  the  success  with  which  the  general  health  of  the 
population  is  maintained.  Mental  deficiency  has  its  most  important  single 
cause  in  heredity,  and  the  control  of  unfavorable  heredity  is  the  practical 
field  of  eugenics.  As  far  as  those  disorders  which  have  been  mentioned  are 
concerned  mental  hygiene  consists  obviously  in  directing  the  attention  of 
those  responsible  for  other  organized  health  movements  to  the  relations  which 
their  work  bears  to  mental  disease  and  mental  defect.  Nevertheless,  there 
is  an  important  field  of  prevention  which  no  other  agencies  than  those  spe- 
cifically devoted  to  mental  hygiene  can  hope  to  enter  successfully;  that  is, 
the  control — largely  during  childhood — of  those  factors  acting  within  the 
mental  life  of  the  individual  which  are  recognizable  early  as  slight  deviations 
from  normal  thinking  and  living,  and  which  ultimately  may  result  in  disastrous 
anti-social  reactions  or  in  the  production  of  grave  forms  of  mental  disease. 
There  is,  in  addition,  a  great  field  in  mental  hygiene  which  has  for  its  objects 
the  protection,  supervision  and  special  training  of  people  with  impaired  or 
naturally  limited  ability  to  adjust  themselves  so  that  through  the  skillful 
efforts  of  others  their  lives  may  be  successful  and  useful,  socially  if  not  bio- 
logically. Facilities  must  be  organized  for  dealing  with  those  incipient  stages 
of  severe  disorders  at  the  very  beginning.  A  conception  of  the  part  of  the 
school  clinic  much  wider  than  that  of  classifying  children  with  reference  to 
intelligence  must  come  into  existence.  The  mental  hygiene  activities  of 
many  unrelated  welfare  organizations  and  city  and  state  departments  must 
be  coordinated  by  an  organization  specifically  established  for  this  purpose. 
This  is  the  task  of  the  mental  hygiene  society.* 


*  Important  and  recent  reprints  on  the  subject  of  mental  disease  and  care  can  be  had  by  application 
to   the   National   Committee  for   Mental  Hygiene,   50   Union  Square,   New   York  City. 


Mental  Diseases  and  Deficiency  503 

Summary  of  Recommendations 
I.    Dealing  with  state  legislation  and  local  ordinances  or  charter   changes. 

A.    State 

1.  State  administration  and  supervision  of  the  institutional  care  and  treatment  of 
persons  with  mental  diseases,  mental  deficiency  and  epilepsy,  and  of  their  guardianship  in 
the  community. 

Legislation  is  recommended  that  will  accomplish  the  following  objects: 

a.  Establishing  a  special  State  Commission  on  Mental  Diseases  for  the  per- 
formance of  the  functions  mentioned  above ;  such  Commission  (headed  by 
a  physician  experienced  in  dealing  with  the  institutional  and  social  aspects 
of  mental  disorders)  to  administer  the  state  hospitals  for  the  insane,  the 
State  Institution  for  the  Feeble-minded,  the  State  Hospital  for  Epileptics 
and  the  Bureau  for  Juvenile  Research  and  to  concern  itself  with  the  broad 
medical  and  community  relationships  of  these  disorders  as  well  as  with 
the  business  administration  of  the  institutions. 

b.  Establishing  a  bi-partisan  State  Institutional  Development  Commission 
composed  of  the  head  of  the  special  Commission  on  Mental  Diseases 
recommended  in  the  preceding  paragraph,  members  of  each  house  of  the 
Legislature  and  persons  not  in  the  service  of  the  state  who  can  bring  special 
knowledge  to  the  task;  such  Commission  to  formulate  a  ten-year  program 
for  the  development  of  the  state's  institutions  for  mental  disorders  in 
accordance  with  a  comprehensive  plan  for  remedying  the  existing  serious 
inadequacy  and  to  present  to  the  Legislature,  at  the  beginning  of  each 
session,  definite  recommendations  for  appropriations  for  the  ensuing  two 
years. 

c.  Licensing  and  inspecting  private  institutions  for  the  care  of  mental 
patients. 

2.  Commitment,  care  and  parole  and  discharge  of  persons  with  mental  diseases. 
Legislation  is  recommended  that  will  accomplish  the  following  objects: 

a.  Removing  present  restrictions  as  to  the  number  of  voluntary  patients  that 
can  be  received  in  state  hospitals. 

b.  Committing  patients  for  observation  for  a  period  of  ten  days  to  state 
hospitals,  psychopathic  hospitals  and  psychopathic  wards  in  general  hos- 
pitals. 

c.  Prohibiting  the  detention  of  persons  awaiting  commitment  in  jails  or  alms- 
houses and  placing  the  responsibility  for  their  care  pending  commitment 
and  reception  in  state  hospitals  in  the  hands  of  health  officers,  except  in 
cities  where  suitable  facilities  are  otherwise  provided. 

d.  Discontinuing  the  personal  appearance  of  mentaj,  patients  in  court. 

e.  Admitting  patients  to  state  hospitals  in  emergencies  upon  the  certificate 
of  two  physicians,  such  admissions  to  be  followed  within  ten  days  by 
discharge  or  court  commitments. 


504  Hospital  and  Health  Survey 


f.  Committing  to  state  hospitals  any  persons  under  trial  in  whom  mental 
disease  is  suspected  upon  order  of  any  trial  judge,  such  commitments 
being  for  observation  only  and  for  a  period  not  less  than  ten  nor  more 
than  thirty  days. 

g.  Authorizing  sending  nurses  and  attendants  from  state  hospitals  to  bring 
from  their  homes  or  places  of  temporary  detention  patients  who  may 
have  been  committed  and  are  awaiting  transfer,  thus  eliminating  the 
services  of  sheriffs  and  police  officers. 

h.  Authorizing  counties  to  pay  examining  physicians  salaries  instead  of  fees 
for  their  services  when  mental  examinations  are  made  in  psychopathic  hos- 
pitals, psychopathic  wards  in  general  hospitals  or  mental  clinics  main- 
taining satisfactory  standards. 

3.     Commitment,  registration,  care,  training,  parole  and  discharge  and  com- 
munity guardianship  and  supervision  of  the  mentally  defective. 

Legislation  is  recommended  that  will  accomplish  the  following  objects: 

a.  Committing  children  and  adults  for  observation  for  a  period  of  ten  days 
to  state  institutions  for  the  feeble-minded,  state  hospitals  for  epileptics, 
psychopathic  hospitals,  psychopathic  wards  in  general  hospitals  or  the 
Bureau  for  Juvenile  Research. 

b.  Committing  mentally  defective  children  and  adults  to  guardianship,  with 
provision  for  transfer  from  this  form  of  commitment  to  institutions  and 
vice  versa. 

c.  Encouraging  the  development  and  coordinating,  under  the  proposed 
State  Commission  on  Mental  Diseases,  organized  facilities  for  the  regis- 
tration and  community  supervision  of  the  mentally  defective.  (See 
IV  A- lb.) 

d.  Eliminating  the  age  of  consent  in  mentally  defective  women  and  girls  who 
have  been  committed  to  institutions  or  to  guardianship. 

e.  Authorizing  sending  nurses  and  attendants  from  state  institutions  for  the 
feeble-minded  and  state  hospitals  for  epileptics  to  bring  from  their  homes 
or  places  of  temporary  detention  patients  who  have  been  committed 
and  are  awaiting  transfer,  thus  eliminating  the  services  of  sheriffs  and 
police  officers. 

f.  Authorizing  counties  to  pay  examining  physicians  salaries  instead  of  fees 
for  their  services  when  mental  examinations  are  made  in  psychopathic 
hospitals,  psychopathic  wards  in  general  hospitals  or  mental  clinics  main- 
taining satisfactory  standards. 

g.  Authorizing  the  proposed  State  Commission  on  Mental  Diseases  to  in- 
spect places  for  the  temporary  detention  of  mentally  defective  persons 
and  homes  and  schools  in  which  delinquent  or  dependent  children  are 
maintained. 


Mental  Diseases  and  Deficiency  505 

h.  Requiring  the  establishment  and  maintenance  of  special  classes  for 
mentally  defective  children  in  every  school  district  in  which  fifteen  or 
more  such  children  are  found,  authorizing  the  payment  by  the  State 
Department  of  Education  of  a  fixed  sum  to  the  local  school  authorities 
for  each  such  class  maintained,  requiring  satisfactory  mental  and  physical 
examinations  of  all  children  before  admission  to  such  classes  and  author- 
izing supervision  of  such  examinations  by  a  psychiatric  advisor  to  the 
State  Department  of  Education. 

4.  Other  state  legislation  affecting  the  insane,  mentally  defective  and  epileptic  and 
furthering  work  in  mental  hygiene. 

Legislation  is  recommended  that  will  accomplish  the  following  objects: 

a.  Developing  the  Bureau  for  Juvenile  Research  so  that  its  original  objects 
may  be  accomplished,  permitting  it  to  receive  children  for  observation 
before  as  well  as  after  they  are  committed  to  the  state  institutions  or  to  the 
custody  of  the  Board  of  Administration. 

b.j  Requiring  the  Juvenile  Court  and  authorizing  other  courts  to  maintain 
mental  clinics  or  to  make  arrangements  with  other  clinics  for  the  routine 
mental  examination  of  juvenile  and  adult  offenders. 

B.     City 

Such  changes  in  local  ordinances  and  city  charter  are  recommended  as  will  permit 
the  establishment  of  the  facilities  recommended  in  the  following  sections. 

II.    Dealing  with  departments  of  state  and  city  government. 

A.    State 

The  following  recommendations  are  made  for  developing  existing  state 
facilities  for  dealing  with  mental  disorders  and  promoting  mental  hygiene. 
Some  of  them  involve  both  legislative  and  administrative  action -and  others 
only  administrative  action: 

1.     Institutional  provisions  for  the  treatment  of  persons  with  mental  diseases. 

a.  Providing  a  new  State  Hospital  for  the  insane,  to  be  constituted  by  adding 
a  new  department  in  the  country  to  the  Cleveland  State  Hospital  and  dis- 
tributing functions  between  the  two  departments  so  that  the  city  depart- 
ment (the  present  institution)  will  be  used  for  receiving  and  intensive 
treatment  center,  infirmaries  for  terminal  conditions,  hospital  for  acute 
general  and  surgical  diseases,  diagnostic  clinic,  laboratories  and  adminis- 
tration and  the  new  department  (which  would  be  the  larger)  for  patients 
in  good  physical  condition  who  require  long,  continued  care  and  who  will 
profit  by  the  facilities  for  industrial  training  and  re-education. 

b.  Providing  adequate  salaries  for  superintendents  of  state  hospitals  (who 
now  receive  lower  compensation  than  in  any  other  state)  assistant  physi- 
cians, nurses  and  occupation  instructors  in  order  that  more  efficient  treat- 
ment services  may  be  built  up. 


.506  Hospital  and  Health  Survey 

c.  Providing  Clinical  Directors  of  Psychiatry  in  all  state  hospitals  to  be 
responsible  for  the  scientific  work  and  for  the  supervision  of  all  training. 

d.  Providing  training  schools  for  nurses  and  for  attendants  in  all  state  hos- 
pitals and  a  Supervisor  of  Nursing  in  the  proposed  State  Commission  on 
Mental  Diseases  to  supervise  and  standardize  such  instruction. 

e.  Instituting  active  after-care  and  social  service  so  that  more  patients  may 
be  paroled  and,  by  following  their  supervision  into  the  community,  the 
durability  of  recoveries  and  remissions  increased.    (See  IV  A-lb.) 

f .  Instituting  a  system  of  mental  clinics  in  the  district  of  each  state  hospital 
for  after-care  and  preventive  work,  and,  in  cities,  cooperating  with  exist- 
ing mental  clinics  so  that  after-care  patients  may  be  seen  by  the  physicians 
who  have  them  under  their  care  while  in  state  hospitals. 

g.  Providing  stewards  at  state  hospitals  so  that  superintendents  will  be 
relieved  from  the  administrative  details  that  now  occupy  a  larger  part 
of  their  time  than  supervising  and  developing  medical  activities. 

h.     Effecting  liaison  with  the  proposed  City  Psychopathic  Hospital  (Psycho- 
pathic Department  of  the  City  Hospital)  for  the  purposes  of  training 
medical  and  nursing  personnel  and  carrying  on  joint  work  in  psychiatric    . 
research. 

2.     Institutional  provisions  for  the  treatment  of  persons  with  mental  deficiency  and 
epilepsy. 

a.  Providing  a  new  state  institution  for  the  feeble-minded  to  which  persons  of 
both  sexes  and  all  ages  will  be  admitted  and  attaching  to  this  and  the 
existing  institution  colonies  for  the  care  and  training  of  boys  and  men 
in  good  physical  condition  and  of  relatively  high  mentality. 

b.  Providing  adequate  salaries  for  superintendents,  assistant  physicians, 
nurses  and  teachers  of  the  State  Institution  for  the  Feeble-minded  and 
the  State  Hospital  for  Epileptics  in  order  that  more  efficient  treatment 
and  training  services  may  be  built  up. 

B.    City 

The  following  recommendations  are  made  for  developing  existing  city 
facilities  for  dealing  with  mental  disorders  and  promoting  mental  hygiene: 

1.     City  Hospital. 

a.  Replacing  the  present  deplorable  facilities  for  the  reception,  observation, 
diagnosis  and  early  treatment  of  mental  patients  with  a  modern  City 
Psychopathic  Hospital  (Psychopathic  Department)  of  from  150  to  200 
beds  with  a  full-time  medical  staff  and  all  modern  facilities  for  treatment 
— including  occupational  therapy,  physiotherapy,  hydrotherapy,  etc. 

b.  Providing  the  proposed  City  Psychopathic  Hospital  with  a  dispensary 
at  the  hospital  and  developing  under  its  control  and  leadership,  besides 
the  Central  Mental  Dispensary,  special  mental  clinics  in  the  Children's 


Mental  Diseases  and  Deficiency  .507 

Court,  the  Municipal  Court,  the  Boys'  School  and  other  agencies  which 
require  the  services  of  psychiatrists,  such  "outposts"  being  supported 
directly  by  the  agencies  served  or  by  appropriations  to  the  City  Hospital 
for  these  specific  purposes  and  constituting  part  of  the  Mental  Clinic 
in  the  proposed  Downtown  Dispensary.     (See  IV  B-l.) 

(This  arrangement  prevents  the  establishment  of  a  number  of  small, 
weak  and  unattached  clinics  and  permits  the  facilities  in  personnel  and 
laboratories  that  a  strong  Psychopathic  Hospital  would  possess  to  be 
widely  employed.) 

c.  Including  nursing  in  the  City  Psychopathic  Hospital  in  the  nursing 
department  of  the  City  Hospital,  pupil  nurses  in  the  training  school 
being  required  to  spend  three  months  in  mental  nursing  and  the  physicians 
and  supervising  nurse  of  the  Psychopathic  Hospital  assisting  in  the 
instruction  of  nurses  in  the  training  school. 

d.  Forming  affiliations  with  other  Nurses'  Training  Schools  in  the  city  and 
elsewhere  so  as  to  give  special  instruction  and  experience  in  mental  nurs- 
ing and,  in  return,  secure  the  services  of  pupil  and  graduate  nurses. 

e.  Strengthening  the  Social  Service  Department  of  the  City  Hospital  by  the 
addition  of  psychiatric  social  workers. 

f.  Utilizing  to  the  fullest  possible  extent  the  teaching  facilities  of  the  City 
Psychopathic  Hospital,  not  only  for  medical  students  and  physicians 
but  occupation  instructors,  social  service  workers  and  others. 

2.     Board  of  Education. 

a.  Providing  a  greater  number  of  special  classes  for  backward  and  mentally 
defective  children  and  improving  the  accommodations  in  special  class 
centers. 

b.  Increasing  the  compensation  of  teachers  of  special  classes  so  that  this 
work  will  be  placed  upon  a  higher  professional  plane. 

c.  Developing  the  present  psychological  clinic  of  the  Board  of  Education 
into  a  School  Mental  Clinic  in  which  psychiatrists,  psychologists  and 
psychiatric  social  workers  can  bring  to  bear  upon  the  mental  problems 
of  school  children  all  the  resources  of  psychology  and  medicine  instead  of 
only  those  which  deal  with  the  measurement  of  intelligence. 

d.  In  such  a  clinic,  widening  the  scope  of  the  study  of  unadjusted  school 
children  to  include  other  mental  problems  than  mental  deficiency  and 
making  the  aim  of  treatment  as  prominent  as  that  of  diagnosis. 

e.  Systematically  encouraging  teachers  and  parents  to  make  use  of  the 
School  Mental  Clinic  recommended  in  the  preceding  paragraph  for  the 
diagnosis  and  treatment  of  psychoneurotic  and  psychopathic  children 
and  those  presenting  conduct  disorders  of  any  kind  (lying,  pilfering,  sex 
delinquencies,  truancy,  etc.). 


508  Hospital  and  Health  Survey 


f.  Correlating  the  work  of  special  classes  for  "exceptionally  bright"  children 
and  for  the  correction  of  speech  defects  with  routine  examinations  and 
individual  studies  in  the  School  Mental  Clinic. 

g.  Including  in  the  instruction  given,  in  teachers'  institute  and  other  train- 
ing courses,  information  regarding  mental  deficiency  and  the  psycho- 
pathic disorders  of  childhood. 

h.  Arranging  for  the  postgraduate  instruction  in  Cleveland  or  elsewhere  of 
teachers  who  desire  to  fit  themselves  especially  for  work  in  special  classes. 

3.  Parochial  Schools. 

a.  Encouraging  the  formation  of  special  classes  for  backward  and  mentally 
defective  children  and  the  free  use  of  the  School  Mental  Clinic  recom- 
mended above  for  diagnosis  and  treatment. 

4.  Courts. 

a.  Establishing  in  the  Juvenile  Court  a  mental  clinic  staffed  by  psychiatrists, 
psychologists  and  psychiatric  social  workers  from  the  proposed  City 
Psychopathic  Hospital  and  the  Downtown  Dispensary  or,  in  case  that 
difficulties  in  making  satisfactory  arrangements  arise,  an  independent 
but  closely  affiliated  clinic.     (See  IV  B-ld.) 

b.  Including  in  the  work  of  such  clinic  the  routine  mental  examinations 
and  individual  studies  of  children  in  the  Boys'  School,  the  Girls'  Home 
and  the  private  agencies  to  which  children  are  sent  by  the  Children's 
Court  for  temporary  detention  or  placement. 

c.  Establishing  as  another  "outpost"  of  the  Psychopathic  Hospital  a  clinic 
in  the  Municipal  Court  which  should  also  conduct  routine  mental  exami- 
nations and  individual  studies  of  persons  in  the  House  of  Correction. 
(See  IV  B-ld.) 

d.  Replacing  the  present  system  of  mental  examination  in  the  Probate 
Court  by  examination  by  the  staff  of  the  Psychopathic  Hospital,  such 
services  to  be  paid  for  by  appropriations  or  allotments  made  by  the 
Probate  Court  to  the  Department  of  Public  Welfare  for  this  purpose. 
(See  I  A-2h  and  I  A-3f.) 

III.    Dealing  with  private  agencies  by  groups. 

The  following  recommendations  are  made  for  more  effective  work  in 
dealing  with  mental  disorders  and  promoting  mental  hygiene  by  private 
agencies : 

A.    State 

1.     Mental  Hygiene  Committee. 

a.  The  newly  organized  Committee  for  Mental  Hygiene  should  receive 
the  support  of  all  those  who  desire  to  see  the  state  assume  the  duties  that 
rightfully  belong  to  it  so  that  local  agencies  need  not  continue  devoting 
a  large  part  of  their  resources  to  the  performance  of  tasks  that  arise  chiefly 


Mental  Diseases  and  Deficiency  509 

from  the  state's  negligence.  Not  until  the  state  has  met  its  obligation 
to  provide  for  the  mentally  defective  and  epileptic  will  the  local  agencies 
— both  public  and  private — be  able  to  devote  themselves  exclusively  to  the 
work  for  which  they  were  created  and  are  maintained  by  public  funds 
or  private  philanthropy.  A  strong  State  Committee  for  Mental  Hygiene, 
with  definite  objects  and  strongly  supported  by  public  spirited  citizens, 
can  do  more  to  accomplish  these  ends  than  any  other  type  of  private 
agency. 

B.    City 

1 .  Hospitals. 

a.  Western  Reserve  University  and  Lakeside  Hospital.  (See  IV  B-2a,  b,  c,  d.) 

b.  In  order  to  carry  their  share  of  the  burden  of  mental  illness  the  various 
hospitals  that  aim  to  be  general  hospitals  in  fact  as  well  as  in  name 
make  provisions  to  care  for  a  few  mental  patients,  especially  those  arising 
in  the  hospital  in  the  course  of  other  illnesses ;  make  more  use  of  the 
neuro-psychiatrists  on  their  visiting  and  consulting  staffs  and  make 
provisions  for  mental  patients  in  their  dispensaries. 

2.  Orphanages  and  Homes. 

a.  Private  charitable  institutions,  especially  those  which  deal  with  dependent 
or  delinquent  children,  wayward  girls  and  unmarried  mothers  will  find 
that  light  can  be  thrown  upon  some  of  their  most  difficult  problems 
by  making  the  freest  use  possible  of  such  clinics  as  those  recommended. 
Institutions  receiving  only  delinquent  children  should  secure  such  aid 
in  every  case  whether  it  seems  to  be  especially  indicated  or  not. 

IV.    Dealing  with  new  agencies  or  private  facilities  to  be  established. 

A.    State 
The  establishment  of  the  following  new  agencies  is  recommended: 

1.     Agencies  that  can  be  successfully  instituted  only  under  the  special  State  Commission 
on  Mental  Diseases  recommended.     (See  I  A- la.) 

a.  Forming  a  joint  purchasing  committee  composed  of  representatives  of 
the  proposed  Commission  on  Mental  Diseases,  the  Board  of  Administra- 
tion, and  superintendents  and  stewards  of  hospitals  and  institutions  in 
the  "mental  disease  group"  the  "charitable  group"  and  the  "correctional 
group"  so  as  to  effect  all  possible  economies  through  joint  purchase 
without  requiring  the  present  administrative  union  of  entirely  different 
kinds  of  state  activities. 

b.  Organizing,  in  the  proposed  Commission  on  Mental  Diseases,  a  Bureau 
of  Mental  Hygiene  that  will  have  supervision  over  state  mental  clinics, 
after-care,  parole  and  social  service  work,  community  supervision  of 
the  mentally  defective  and  intensive  experiments  in  the  prevention  of 
mental  diseases  and  mental  deficiency. 


510  Hospital  and  Health  Survey 

c.  Organizing  directly  under  the  Commission  on  Mental  Diseases  at  one  of 
the  State  Hospitals  or  at  the  Bureau  for  Juvenile  Research  a  central 
Psychiatric  Institute  for  study  and  research  into  the  causes,  nature 
and  treatment  and  prevention  of  mental  diseases,  mental  deficiency  and 
epilepsy,  and  for  direction  and  coordination  of  the  scientific  work  of  the 
hospitals  and  institutions. 

B.   City 

The  establishment  of  the  following  new  agencies  is  recommended: 

1.  Mental  Clinic  in  the  Downtown  Dispensary. 

a.  Establishing  in  the  Downtown  Dispensary,  that  has  been  recommended 
in  various  sections  of  the  Survey,  a  large  and  fully  staffed  and  equipped 
Mental  Clinic  that  shall  be  a  branch  of  the  City  Psychopathic  Hospital 
(Psychopathic  Department  of  the  City  Hospital)  and  conducted  by  that 
institution. 

b.  Providing  for  the  closest  cooperation  between  this  Mental  Clinic  and 
the  other  departments  of  the  Downtown  Dispensary  and  the  dispensary 
of  the  proposed  Psychiatric  Clinic  of  Western  Reserve  University. 

c.  Providing  for  carrying  on  mental  clinics  in  connection  with  the  Juvenile 
Court  and  other  agencies,  except  the  School  Mental  Clinic  of  the  Board 
of  Education,  as  "outposts"  of  the  Mental  Clinic  of  the  Downtown 
Dispensary.     (See  II  B-4a,  b,  c.) 

d.  Utilizing  the  teaching  facilities  of  the  Mental  Clinic  of  the  Downtown 
Dispensary  in  the  same  way  as  those  of  the  City  Psychopathic  Hospital. 

2.  Western  Reserve  University  and  Lakeside  Hospital. 

a.  Establishing  a  University  Psychiatric  Clinic  of  from  40  to  60  beds  as 
an  integral  part  of  Lakeside  Hospital  for  the  reception,  treatment  and 
study  of  mental  diseases,  especially  those  types  most  frequently  seen  in 
general  medical  and  surgical  practice  and  most  likely  to  be  benefited 
by  treatment  under  the  conditions  that  exist  in  such  a  psychiatric  de- 
partment of  a  general  hospital. 

b.  Establishing  in  connection  with  the  University  Psychiatric  Clinic  recom- 
mended in  the  foregoing  paragraph,  a  dispensary  particularly  for  the 
same  types  of  cases  as  those  received  in  the  clinic. 

c.  Utilizing  to  the  greatest  possible  extent  the  facilities  of  the  University 
Psychiatric  Clinic  and  Dispensary  for  medical  students  and  those  in 
other  departments  of  the  University  who  would  be  aided  by  the  study  of 
psychopathology  under  clinical  conditions. 

d.  Effecting  close  cooperation  between  the  University  Psychiatric  Clinic 
and  the  City  Psychopathic  Hospital  and  its  various  "outposts." 


Mental  Diseases  and  Deficiency  511 

3.     Welfare  Organizations. 

a.  Organizing  a  Cleveland  Mental  Hygiene  Committee,  in  which  all  other 
welfare  organizations  should  be  represented  to  coordinate  all  the  activi- 
ties of  voluntary  social  agencies  that  deal  largely  with  mental  hygiene 
problems,  to  conduct  the  "mental  test  registry,"  to  aid  public  agencies 
(especially  the  proposed  City  Psychopathic  Hospital  and  its  various 
mental  clinics,  and  the  School  Mental  Clinic)  and  to  cooperate,  in 
measures  affecting  state  institutions  or  state  policies,  with  the  Ohio 
State  Committee  for  Mental  Hygiene. 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

X.     Hospitals  and  Dispensaries. 

XI.     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 


The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 


THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Pkemieh  Press 

Cleveland,  O. 


Industrial   Medical   Service 

Women  and  Industry 
Children  and  Industry 


Part  Seven 


Cleveland     Hospital     a  rj'd 
Health     Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -   Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators: 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

I.        Industrial  Medical  Service  Page 

Introduction : 525 

The  Industries  of  Cleveland.... 525 

Medical  Service  in  Industry- 
Industrial  Physicians 526 

Industrial  Nursing ._ 529 

Visiting  Nursing... 531 

Clerical  Personnel... __ ._ _.  532 

Dispensary  Equipment . 533 

Cost  of  Service 533 

Administrative  Relations : 534 

Medical  Service  in  Non-industrial  Establishments 535 

Medical  Service  Beyond  the  Plant 536 

Industrial  Medical  Records _.  537 

Absenteeism  Due  to  Sickness 541 

Physical  Examinations 542 

Special  Services 

Industrial  Psychiatry.... 544 

Industrial  Dental  Service. 545 

Industrial  Ocular  Service 545 

Tuberculosis 546 

Venereal  Diseases. 547 

Rehabilitation  of  Industrial  Cripples 547 

The  Small  Establishment ..I 550 

Industrial  Hospitals.... _ : 552 

The  Training  of  Industrial  Physicians  and  Nurses 552 

Public  Health  Authorities  and  Industrial  Hygiene. 553 

Recommendations 554 

II.      Women  and  Industry 

Introduction .. . _  557 

Conditions  in  Various  Occupations  Employing  Women 
Industrial  Establishments 

The  Metal  Trades _ 559 

Textile  and  Knitting  Mills 561 

The  Garment  Trades 1 561 

Candy  Factories : _ 562 

Miscellaneous  Industrial  Establishments 562 

General  Observations 

Hours  of  Work... 563 

Earnings __ ; 564 


TABLE  OF  CONTENTS— Continued  Page 

Additional  Benefits 564 

Recreation 1 564 

Vacations . 565 

Supervision . . ~  565 

Physical  Conditions  of  Work 567 

Mercantile   Establishments.. 568 

Public  Service  Organizations 

Laundries... , 569 

Hotels : 570 

Restaurants — .  571 

Public  Utilities 571 

General  Discussion 

Night  Work..... 571 

HomeWork 1 573 

Day  Nurseries , 574 

Mothers'  Pensions 575 

Recommendations 575 

Community  Interest— 576 

III.    Children  and  Industry- 
Introductory 579 

Legal  Provisions  for  Children  15-18  Going  to  Work 581 

Statistics  for  Children  in  Industry  in  Cleveland,  1919 583 

Where  Children  Work 

Occupations  Employing  Children. . 588 

Manufacture  of  Confectionery 590 

Manufacture  of  Hosiery  and  Knit  Goods... 590 

The  Metal  Trades 591 

Printing  and  Publishing 592 

Retail  and  Wholesale  Trade 592 

Telephone  and  Telegraph  Work — 593 

Street  Trades .-  597 

Agricultural  Work  and  Domestic  Service 602 

Health  of  Children  at  Work 

Medical  Examinations  of  Children  for  Work  Permits.. 603 

Suggested  Content  of  Ohio  Law  re  Health  Certificate 607 

Subnormal  Children  in  Industry 608 

Summary  of  Standards  of  Physical  Fitness  for  Children  Enter- 
ing Employment —  610 

Education's    Responsibility _ — 613 

Junior  Vocation  Departments - 615 

Suggested  Plan  of  Organization  for  a  Vocational  Guidance  Bureau 617 

Summary  of  Recommendations 619 

Appendix 

Tables 622 


REPORT  OF  THE  INDUSTRIAL  DIVISION 
PREFACE 

In  an  industrial  city  such  as  Cleveland  it  is  not  possible  to  make  a  com- 
prehensive study  of  the  health  of  the  community  without  consideration  of 
the  relations  of  health  and  industry.  Certain  of  these  relations  are  the 
matter  of  this  report. 

The  Industrial  Division  of  the  Hospital  and  Health  Survey  has  been 
concerned  with  three  fields  of  industrial  activity:  medical,  surgical  and 
nursing  service  in  industry;  the  employment  of  women  and  the  employ- 
ment of  children.     These  three  subjects  are  discussed  separately. 

All  recommendations  and  for  the  most  part  the  discussion  of  various 
topics  relate  specifically  to  conditions  as  observed  in  Cleveland,  though  it 
is  true  that  many  other  industrial  cities  present  similar  problems. 

The  Survey  is  indebted  to  the  Committee  for  the  Study  of  Public  Health 
Nursing  Education  for  designating  Mrs.  Anna  M.  Staebler  to  aid  in  the 
study  of  industrial  nursing  and  to  the  Consumers'  League  of  Ohio  which 
contributed  the  services  of  Miss  Florence  V.  Ball,  who  has  conducted  the 
study  of  children  and  industry. 

The  Survey  wishes  also  to  acknowledge  its  appreciation  of  the  coopera- 
tion and  assistance  offered  by  the  industrial  organizations  of  Cleveland  and 
by  numerous  individuals  and  agencies  in  the  city  and  state  which  have 
freely  aided  in  these  studies. 


Health    and    Industry 

Industrial   Medical   Service 
By  Wade  Wright,  M.  D. 

INTRODUCTION 

IN  undertaking  to  study  existing  measures  for  the  safeguarding  of  the 
health  of  industrial  workers  it  was  fully  realized  that  detailed  consideration 
of  working  conditions,  of  sanitation,  of  accident  hazards  and  of  industrial 
health,  was  not  possible  in  the  course  of  a  brief  survey.  It  has  been  the 
purpose  of  those  conducting  this  inquiry  to  obtain  certain  essential  data 
regarding  the  medical  organization  which  various  industrial  and  mercantile 
establishments  have  developed  for  the  care  of  the  health  of  their  employes, 
to  estimate  as  accurately  as  might  be,  the  probable  efficacy  of  such  organiza- 
tion and  to  present  in  this  report  the  findings  of  such  an  inquiry  together  with 
an  expression  of  opinion  regarding  the  merits  of  certain  features  observed, 
and  ways  and  means  for  the  remedying  of  the  more  outstanding  defects. 

It  is  to  be  remembered  that  the  Survey  was  without  legal  authority  to 
enter  and  inspect  industrial  or  other  establishments  and  that  this  study  has 
been  made  possible  only  through  the  courtesy  and  cooperation  of  the  em- 
ployers of  the  city. 

The  information  here  presented  was  obtained  by  questionnaire,  by  visit 
and  by  conference.  It  was  not  practicable  to  visit  all  of  the  large  industrial 
establishments,  but  the  great  majority  of  plants  employing  over  five  hun- 
dred persons  in  which  medical  service  is  rendered,  were  visited  by  one  of 
the  four  members  of  the  staff  of  the  Industrial  Division. 

In  all,  about  one  hundred  organizations  of  various  sizes  were  carefully 
studied  and  information  secured  in  some  detail  regarding  many  more. 

For  the  purpose  of  this  report  certain  observations  relating  to  industry 
will  be  separated  from  those  concerning  mercantile  establishments,  the  con- 
struction trades  and  the  public  utilities. 

THE  INDUSTRIES  OF  CLEVELAND 

The  statistical  studies  of  the  number  and  size  of  industrial  plants  were 
based  upon  the  "Directory  of  Ohio  Manufacturers"  issued  by  the  Indus- 
trial Commission  of  Ohio  in  1918.  The  information  there  published  has  been 
corrected  by  data  more  recently  obtained,  and  though  the  resulting  figures 
are  not  accurate  they  are  probably  a  fair  approximation  of  the  facts. 

In  Table  I.,  published  in  the  appendix,  is  shown  the  division  of  1,521 
industrial  organizations  into  several  size-groups,  together  with  the  group- 
total  number  of  employes,  the  average  number  of  employes  per  establish- 
ment and  the  percentages  of  establishments  and  employes  in  each  group. 

Approximately  74  per  cent  of  the  city's  industrial  workers  are  engaged  in 
establishments  employing  200  or  more,  organizations  of  this  size  constituting 


,>26  Hospital  and  Health  Survey 

only  12  per  cent  of  the  total  number  of  industrial  organizations.  57  per  cent  of 
the  employes  are  engaged  in  establishments  employing  500  or  more,  5.3  per 
cent  of  the  organizations;  and  43  per  cent  of  the  employes  work  in  establish- 
ments employing  1,000  or  more,  2.6  per  cent  of  all  organizations. 

It  is  evident,  with  so  great  a  portion  of  all  industrial  operatives  employed 
in  a  relatively  small  number  of  large  establishments,  that  medical  service 
would  reach  a  very  considerable  number  of  workers  if  it  were  rendered  in 
the  larger  plants. 

MEDICAL  SERVICE  IN  INDUSTRY 

Table  II.  presents  the  findings  relating  to  medical  service  in  industrial 
establishments  of  various  sizes.  It  was  perhaps  inevitable  that  in  certain 
instances  the  information  obtained  from  organizations  was  inexact.  This 
was  true  of  some  statements  regarding  the  place  of  the  medical  department 
in  the  scheme  of  administration  and  its  relation  to  the  rest  of  the  industrial 
organism  and  regarding  the  status  of  physicians  employed  part  time  and  on 
call.  It  has  been  necessary  in  consequence  that  the  staff  rather  freely  in- 
terpret some  of  these  statements. 

In  estimating  the  number  of  firms  furnishing  medical  service  a  rough 
standard  of  adequacy  has  been  accepted.  The  presence  in  a  plant  of  a 
first-aid  cabinet  which  might  be  supplemented  in  the  event  of  a  serious 
emergency  by  the  attention  of  a  neighborhood  physician  has  not  been  reck- 
oned as  "medical  service."  Those  plants  employing  trained  nurses  for  dis- 
pensary work  have  been  rated  as  furnishing  medical  service  even  though 
physicians  were  seldom  called  in. 

The  quality  of  medical  service  rendered  in  the  establishments  which 
have  been  considered  as  furnishing  service  undoubtedly  ranges  between 
widely  separated  extremes.  In  comparatively  few  instances  has  it  been 
found  to  be  of  a  high  order,  judged  by  the  best  standards  of  industrial  medi- 
cine and  surgery  as  practiced  in  this  country. 

It  is  noteworthy  and  most  creditable,  however,  that  about  one-half  of 
the  industrial  workers  of  the  city  are  upon  occasion  receiving  some  sort  of 
medical  attention  in  industrial  plants. 

The  dressing  of  industrial  injuries  of  course  demands  immediate  atten- 
tion and  it  is  true  and  to  be  expected  that  there  is  a  concentration  of  person- 
nel and  service  to  meet  this  first  need.  A  relatively  small  amount  of  time 
and  service  is  devoted  to  other  than  surgical  work.  No  effort  has  been  made 
by  the  Survey  to  appraise  the  quality  of  surgical  work  done  by  industrial 
surgeons  in  the  city,  but  there  is  much  evidence  that  Cleveland  is  fortunate 
in  having  a  group  of  interested,  conscientious  and  able  surgeons  giving  their 
time  especially  to  industrial  cases. 

Industrial  Physicians 

In  Table  III.  are  tabulated  data  concerning  the  medical  department 
personnel  of  establishments  rendering  medical  service. 


Health     and     Industry  527 

The  Survey  has  knowledge  of  but  seven  physicians  employed  upon  a  full- 
time  basis  in  the  industries  of  Cleveland.  There  is  a  much  larger  group, 
numbering  over  twenty,  who  are  identified  almost  exclusively  with  indus- 
trial practice,  including  a  number  of  surgeons  who  are  each  engaged  on  a 
part-time  or  visit  basis  by  several  firms. 

There  has  been  an  interesting  and  important  development  of  medical 
partnerships  which  purpose  to  render  comprehensive  service  to  their  clients, 
including  dispensary  administration  and  health  supervision  as  well  as  indus- 
trial medicine  and  surgery.  There  is  much  to  be  hoped  of  this  type  of  organ- 
ization, especially  in  connection  with  small  establishments,  with  contracting 
and  construction  work  and  those  firms  not  in  a  position  to  command  the  full 
service  of  an  industrial  physician  as  the  administrative  officer  of  a  medical 
department. 

Industrial  medical  service  as  at  present  conceived  is  comparatively  new, 
crudely  developed  and  far  from  being  standardized.  Industries  have  drawn 
into  their  medical  departments  a  variety  of  types  of  physicians. 

In  Cleveland  there  are  a  few  highly  skilled  industrial  physicians,  trained 
to  consider  the  intricate  inter-relations  of  medicine  and  industry,  possessed 
of  wide  technical  knowledge  of  their  special  field. 

There  is  another  group  of  physicians  doing  little  but  casualty  surgery, 
some  of  them  eminently  capable  and  many  of  them  less  so.  As  a. rule  these 
men  are  frankly  interested  in  nothing  but  surgical  conditions,  but  many  will 
consent  nevertheless  to  submit  opinions  upon  any  matters  relating  to  health 
and  sanitation,  including  obscure  poisonings  or  involved  questions  of  indus- 
trial hygiene. 

A  third  class  includes  men  who  have  been  drawn  into  industry  from  gen- 
eral practice,  not  infrequently  in  a  sense,  against  their  desire.  Often  the 
basis  of  selection  of  such  physicians  was  curious.  They  were  in  many  in- 
stances the  attending  family  physician  of  plant  executives.  They  are  apply- 
ing in  industry  methods  very  similar  to  those  which  they  formerly  employed 
in  private  practice,  with  probably  the  same  degree  of  conscientiousness  and 
scientific  honesty  which  characterized  their  work  previously.  Many  of 
them  become  capable  executives  and  well  qualified  industrial  physicians. 
They  are,  however,  strikingly  indicative  of  the  lack  of  comprehension  among 
those  directing  industrial  establishments  of  the  importance  of  selecting  for 
plant  physicians,  men  technically  equipped  to  render  a  technical  service  and 
who  are  possessed  of  proper  personality  and  ability  to  develop  with  and  be- 
yond assigned  tasks. 

Another  group,  happily  diminishing,  is  made  up  of  incapables,  men  who 
have  not  succeeded  in  general  practice,  who  have  drifted  near  financial  rocks 
and  who  eagerly  welcome  even  the  small  salaries  or  fees  which  they  may 
secure  in  establishments  administered  by  those  who  still  are  of  the  impression 
that  any  doctor  is  a  good  doctor,  and  if  secured  cheaply,  a  better  one  for 
their  purposes. 

There  was  a  time,  not  long  ago,  when  industry  diligently  sought  for  the 
struggling   young   physician    and,    finding   him,    offered    him   employment. 


528  Hospital  and  Health  Survey 

Usually  the  salary  was  very  small,  but  the  collateral  inducements  glowing. 
The  young  man  was  informed  that  despite  the  low  salary  he  would  be  able 
to  secure  a  splendid  income  by  the  simple  means  of  developing  a  private 
practice  among  the  company's  employes. 

The  glowing  prophecy  has  been  fulfilled  and  the  physician,  perhaps  no 
longer  young  and  struggling,  has  a  splendid  income,  practising  among  the 
employes. 

The  public  views  with  alarm  and  suspicion  and  reads  editorials  about, 
public  officials  who  personally  benefit  through  their  positions,  but  industry 
has  sought  and  welcomed  the  physician  who  comes  to  advise  and  remains 
to  operate.  Industry  does  not  aim  to  employ  superintendents  or  treasurers 
upon  such  a  basis  of  remuneration,  why  physicians? 

Cleveland  is  not  without  numerous  industrial  physicians  whose  incomes 
are  very  appreciably  augmented  from  the  personal  practice  worked  up  in 
industrial  dispensaries.  The  cough  which  takes  a  laborer  to  his  plant  dis- 
pensary may  carry  him  rather  unexpectedly  still  farther  to  the  company 
doctor's  down-town  office  and  a  tonsillectomy  operation,  and  beyond  that 
into  a  dazed  state  of  financial  stringency.  Or  by  a  particularly  fortuitous 
arrangement,  one  involving  many  thousands  of  operatives  in  Cleveland,  the 
company  physician  or  surgeon  may  collect  within  the  company  dispensary 
his  personal  fee  for  professional  services  rendered. 

It  is  not  dishonest  or  unethical  practice,  any  more  than  is  that  of  the 
concessionaire  who  sells  pie  by  the  plant  gate,  and  there  are  honorable  and 
able  men  engaged  in  it.  But  it  is  of  questionable  value  to  any  employer 
with  whom  the  health  of  his  employes  is  a  matter  of  real  concern.  Indus- 
trial physicians  should  be  employed  to  render  specific  services.  If  it  is  the 
feeling  of  the  management  of  an  industrial  establishment  that  they  do  not 
wish  to  undertake  the  care  of  disabilities  other  than  those  arising  out  of 
industrial  injuries,  the  services  of  physicians  in  their  employ  should  be 
restricted  to  such  cases.  Under  no  circumstances  should  physicians  be 
permitted  to  recruit  private  patients  under  the  guise  of  their  official  posi- 
tions as  company  servants.  Such  employes  as  need  care  beyond  that  fur- 
nished by  the  company  should  be  referred  to  competent  practitioners  not 
on  the  company's  medical  staff.  The  situation  of  an  industrial  physician  in 
an  industrial  dispensary  is  quite  analogous  to  that  of  a  physician  on  the 
visiting  staff  of  one  of  the  many  reputable  hospitals  which  forbid  staff  physi- 
cians to  receive  dispensary  or  hospital  cases  as  private  patients  except  under 
very  special  circumstances. 

The  temptation  to  enlarge  a  personal  practice  in  this  manner  is  compli- 
cated by  other  obvious  evils,  such  as  unnecessary  treatment  or  operations, 
intrusions  upon  the  practices  of  fellow  physicians  and  inevitable  exploitation 
of  workers. 


Health     and     Industry  529 

The  Survey  recommends  that  industrial  physicians  be  selected  with  regard 
for  their  professional  and  executive  abilities  and  that  only  the  well  qualified 
be  chosen;  that  they  be  remunerated  upon  a  basis  commensurate  with  the 
amount  and  character  of  services  expected  of  them ;  that  they  be  not  permitted 
to  combine  with  their  official  duties  personal  practice  among  the  company 
personnel. 

Industrial  Nursing 

Industrial  nursing  is  perhaps  less  standardized  than  industrial  medicine, 
for  the  duties  assigned  to  plant  nurses  vary  with  plant  physicians,  types  of 
industries  and  of  employes  and  the  purposes  and  fancies  of  plant  executives. 
Of  these  several  factors  the  last  is  probably  the  most  potent.  Rarely  is  a 
capable  nurse  selected  and  encouraged  to  develop  and  extend  her  field  of 
usefulness.  She  is  frequently  added  to  the  payroll  in  much  the  same  spirit 
with  which  such  employes  as  doorkeepers  or  telephone  operators  are  added. 

The  great  majority  of  industrial  nurses  in  Cleveland  are  registered  trained 
nurses.  Most  of  them  have  entered  industry  after  a  period  of  private  duty 
nursing,  others  directly  from  hospital  training  schools.  It  is  of  course  to 
be  expected,  as  in  the  case  of  physicians,  that  the  degree  of  excellence  of 
training  varies.  Again,  as  with  physicians,  some  are  well  qualified  to  do 
industrial  work  and  are  intensely  interested  in  the  progress  of  the  new  pro- 
fession; some  have  sought  the  short  hours  and  freedom  of  the  industrial 
world,  rather  than  the  strain  and  uncertainty  of  private  duty  nursing;  and 
others  among  the  least  capable  of  the  nursing  profession  have  drifted  in. 

A  small  portion  of  industrial  nurses  in  the  city  are  not  registered  nurses 
and  are  not  graduates  of  hospital  training  schools.  A  number  have  had 
short  courses  in  first-aid,  others  gained  their  knowledge  of  emergency  surgery 
as  dressing  assistants.  Some  of  them  are  very  able  and  others  obviously 
masquerading  in  nurses'  uniforms  and  are  probably  more  of  a  liability  than 
an  asset  to  the  firms  employing  them.  One  may  safely  venture  the  assertion 
that  in  certain  instances  executives  employing  untrained  nurses  are  not  aware 
of  their  real  professional  status. 

There  is  undoubtedly  a  place  in  industrial  medical  service  for  practical 
nurses  or  nurses'  assistants,  serving  with  and  under  the  direction  of  compe- 
tent medical  or  nursing  authority.  At  present  practical  nurses  are  found  in 
almost  eyery  instance  in  charge  of  their  own  departments. 

In  establishments  where  there  is  no  organized  medical  service  certain 
duties  ordinarily  assigned  to  a  nurse  are  assumed  by  matrons  or  by  members 
of  the  clerical  forces.  Such  an  arrangement  is  warranted  only  in  a  small 
organization. 

The  progress  of  industrial  hygiene  has  been  due  in  large  measure  to  the 
contributions  of  industrial  nurses.  The  truth  of  this  may  be  readily  evi- 
denced if  one  endeavors  to  withdraw  from  the  fabric  of  industrial  organiza- 
tions the  threads  representative  of  the  services,  the  influence  and  the  person- 
alities of  able  industrial  nurses.     It  is  the  industrial  nurse  in  many  instances 


530  Hospital  and  Health  Survey 

who  stands  in  the  minds  of  employes  as  the  most  kindly,  most  wholesome 
human  element  in  a  big  industrial  machine.  Her  achievement,  however, 
must  depend  in  great  degree  upon  the  intelligent  support  and  guidance  of 
the  plant  administration. 

It  is  to  be  expected  that  the  personality,  abilities  and  ambitions  of  indus- 
trial nurses  should  in  general  be  in  keeping  with  the  types  of  industrial 
organizations  which  employ  them  and  the  purposes  for  which  they  are  em- 
ployed. It  is  as  idle  to  criticize  many  an  industrial  nurse  for  failure  to  real- 
ize fully  her  opportunities  for  constructive  health  work  as  it  is  to  condemn 
the  surviving  old  type  contract  surgeon  who  is  competent  simply  to  bask  on 
the  sunny  side  of  the  payroll  as  "a  doctor,"  quite  as  content  as  his  employ- 
ers are  to  have  him  there. 

Not  infrequently  the  nurse  gives  far  more  service  than  is  expected  of  her, 
little  though  that  service  may  be.  She  finds  slight  stimulus  to  better  effort. 
If  she  writes  a  poor  report,  it  serves  as  well  as  a  good  one,  for  it  doubtless 
receives  but  a  casual  glance  from  an  uninterested  front  office  executive. 
Perhaps,  as  in  one  plant,  she  finds  no  official  who  considers  it  his  duty  to 
review-  that  report,  so  she  submits  none.  She  may  attempt  to  extend  her 
usefulness,  as  in  another  Cleveland  establishment,  but  the  employes  make 
such  increased  use  of  her  department  that  she  is  retired  to  her  own  reserva- 
tion, instructed  to  remain  there.  If  the  professional  advice  she  offers  is 
unsound,  there  is  no  one  the  wiser,  certainly  not  the  recipient  of  the  advice. 

If  she  has  had  fairly  good  training,  is  reasonably  decorative,  has  a  ready 
suggestion  for  the  relief  of  the  general  manager's  indigestion  and  the  em- 
ployes like  her,  she  may  be  an  eminent  success  as  an  industrial  nurse  in  almost 
any  one  of  the  large  group  of  plants  where  physicians  are  employed  part 
time  or  on  call. 

The  employment  of  nurses  with  little  or  no  medical  supervision  has  led 
in  Cleveland  to  a  lowering  of  accepted  standards  of  nursing  and  medical 
practice  regarding  medication.  With  the  exception  of  instances  so  rare  as 
to  be  practicably  negligible  the  industrial  nurses  of  the  city  are  freely  ad- 
ministering drugs  for  the  relief  of  minor  ailments  without  individual  or 
standing  orders  of  physicians.  There  is  constant  and  free  use  made  of 
various  sedatives  for  the  relief  of  headaches,  coughs  and  divers  pains  and  of 
cocaine  for  the  removal  of  foreign  bodies  in  the  eye.  Though  it  is  not  to  be 
questioned  that  many  or  most  nurses  are  qualified  to  use  these  drugs  with 
discretion,  the  fact  remains  that  indiscriminate  medication  of  this  kind  is 
not  in  accordance  with  modern  standards  of  medical  treatment  and  unauthor- 
ized, as  in  these  instances,  it  is  in  direct  violation  of  the  medical  practice 
act  of  the  state. 

Isolated,  as  most  industrial  nurses  are,  from  professional  associations, 
confined  to  their  duties  for  the  entire  weekly  working  period,  they  naturally 
tend  to  become  somewhat  limited  in  conception  of  their  duties  and  their 
opportunities.     They  are  pioneers  in  their  respective  establishments  often, 


Health     and     Industry  531 

each  one  endeavoring  to  work  out  her  own  problems,  a  difficult  task  when 
no  precedents  are  at  hand  and  no  competent  advice  readily  available. 

There  is  urgent  necessity  in  Cleveland,  as  in  other  cities,  for  some'  means 
of  carrying  to  industrial  nurses  the  counsel  and  technical  assistance  which 
most  need  and  many  desire.  The  present  Industrial  Nurses'  Club  is  presum- 
ably of  real  value  in  this  connection  but  its  services  are  quite  inadequate.  It 
would  be  much  to  the  advantage  of  organizations  employing  industrial 
nurses  to  contribute  to  a  common  fund  devoted  to  the  maintenance  of  a 
center  for  gatherings  of  industrial  nurses;  of  a  good  library  on  industrial 
hygiene,  including  related  periodicals;  of  a  series  of  conferences  and  of  one 
or  more  well  salaried  counseling  industrial  nurses.  Such  a  counsellor,  wisely 
chosen,  rendering  an  expert  technical  consultation  service,  could  be  of  unques- 
tioned assistance  to  industrial  nurses  and  plant  executives  and  would  in  no 
sense  conflict  with  established  relations  of  authority  and  responsibility. 


Visiting  Nursing 

It  has  been  difficult  to  determine  with  any  exactness  the  number  of 
firms  whose  nurses  make  visits  to  the  homes  of  employes.  In  a  small  num- 
ber of  establishments  visiting  nursing  is  an  accepted  part  of  the  medical 
department  routine,  in  others,  visits  to  the  homes  of  sick  workers  are  made 
infrequently.  A  total  of  22  firms  are  recorded  as  providing  at  least  occa- 
sional visiting  nursing  services;  13  of  these  firms  employing  1,000  or  more; 
7  firms  employing  500  to  1,000,  and  2  firms  from  200  to  500  employes.  In 
no  instance  does  a  visiting  industrial  nurse  do  bedside  nursing,  at  its  best 
the  purpose  of  her  visit  being  rather  to  determine  whether  or  not  the  sick 
or  injured  worker  is  receiving  proper  care. 

Industry  has  made  occasional  use  of  nurses  furnished  by  the  Visiting 
Nursing  Association.  A  more  extended  utilization  of  such  an  established 
service  might  be  advantageous. 

In  Cleveland  a  considerable  number  of  nurses  employed  in  industry  for 
visiting  do  not  report  to  the  medical  department  but  are  responsible  to 
employment  officials.  Their  task  is  to  visit  the  homes  of  absentees  to  de- 
termine the  cause  of  absence  and  to  exert  such  influence  as  they  may  to 
induce  the  delinquent  to  return  to  work. 

Such  service,  valuable  though  it  may  be,  is  not  visiting  nursing,  is  not  a 
part  of  medical  care  or  supervision  and  the  employment  of  nurses  for  this 
work  is  frequently  a  transparent  subterfuge  of  employment  departments 
used  to  mask  the  real  purpose  of  such  visiting.  It  rarely  fails  to  discredit 
the  organization  responsible  for  the  activity  and  to  lower  the  respect  of 
employes  for  the  plant  nurses.  With  good  reason  employes  resent  the  com- 
ing to  their  homes  unasked  of  women  who  wear  the  uniform  of  nurses  but 
who  in  purpose  and  in  fact  belong  to  the  company  espionage  service  and 
not  to  its  health  department. 


532  Hospital  and  Health  Survey 

It  is  obvious  that  absence  follow-up  can  best  be  done  by  visitors  who  are 
qualified  to  discern  illness  when  it  exists,  but  nurses  are  so  few  and  absentee- 
ism so  prevalent  that  it  is  of  doubtful  wisdom  to  assign  nurses  to  routine 
absence  follow-up  instead  of  to  visiting  of  the  known  or  suspected  sick.  In 
any  event,  visiting  nurses  should  be  considered  as  medical  department  per- 
sonnel and  their  reports  should  be  part  of  the  medical  department  records. 

RECOMMENDA  TIONS 

The  survey  recommends  that: 

Industrial  nurses  be  graduate,  registered  nurses.  That  they  be  employed 
in  the  practice  of  nursing  or  in  the  maintenance  of  the  physical  welfare  of 
establishment  personnel. 

That  industrial  nurses  be  carefully  chosen  for  professional  fitness  and 
for  such  qualities  of  personality  and  character  as  will  enable  them  to  fulfill  their 
many  responsibilities. 

That  practical,  untrained  nurses  be  employed  only  under  competent 
medical  or  nursing  supervision. 

That  industrial  nurses  in  establishments  where  they  are  directly  and 
wholly  responsible  to  executive  officers  rather  than  to  industrial  physicians  be 
granted  such  authority  and  receive  such  support  as  may  be  necessary  for 
the  development  of  their  fullest  usefulness.  That  industrial  physicians  re- 
member that  the  industrial  nurse  must  be  more  than  a  handmaiden  of  the 
medical  profession. 

That  medication  without  the  individual  or  standing  orders  of  a  physi- 
cian should  be  prohibited  in  industrial  establishments  as  it  is  in  law. 

That  encouragement  and  assistance  be  offered  by  industry  to  industrial 
nurses  in  their  efforts  to  maintain  contact  with  progressive  movements  in 
their  rapidly  developing  profession. 

That  visiting  nursing  be  considered  as  a  normal  function  of  industrial 
medical  service  to  be  exercised  as  required  or  desirable. 

That  industrial  visiting  nurses  be  rated  as  medical  department  personnel. 
That  they  visit  the  known  or  suspected  sick  and  be  not  employed  for  routine 
absence  follow-up  from  employment  departments. 

Clerical  Personnel 
Clerical  personnel  of  medical  departments  in  Cleveland  is  limited.  It  is 
about  as  rare  and  found  in  about  the  same  places  as  adequate  dispensary 
records.  Seven  firms  employ  a  total  of  fourteen  clerks  in  connection  with 
industrial  dispensaries.  Efficient  health  administration  is  as  dependent 
upon  proper  dispensary  records  as  efficient  production  and  sales  methods 
upon  proper  cost  accounting. 

In  all  industrial  dispensaries  there  is  need  of  some  clerical  work.  Nurses 
and  physicians  are  trained  for  medical  service.  If  clerical  work  is  excessive 
it  should  be  performed  by  clerks  and  not  by  the  medical  or  nursing  staff. 


Health     and     Industry  .533 

Dispensary   Equipment 

No  detailed  consideration  of  the  equipment  of  industrial  dispensaries  is 
included  in  this  report.  Excellent  work  can  be  done  with  meager  equip- 
ment and  worthless  work  in  the  midst  of  much  white  enamel. 

It  has  been  a  matter  of  some  interest  that  with  a  few  exceptions  the 
medical  departments  rendering  the  best  service  in  the  city  are  in  poor  quar- 
ters and  possessed  of  inferior  dispensary"  fittings.  The  equipment  of  many 
of  the  most  elaborately  furnished  suites  has  apparently  exhausted  the  inter- 
est and  thought  of  those  responsible  for  medical  administration. 

It  is  certain  that  an  efficient  staff  will  be  aided  by  adequate  and  convenient 
equipment  as  well  as  by  quarters  which  are  accessible  and  sufficiently  large 
for  the  number  of  cases  to  be  handled. 

Most  of  the  industrial  X-Ray  work  in  the  city  is  done  by  hospitals  or 
firms  specializing  in  this  service.  A  small  number  of  firms  have  installed 
apparatus  for  such  purposes  as  radiographing  teeth  or  minor  injuries.  Sev- 
eral establishments  have  apparatus  enabling  them  to  do  practically  all  grades 
of  X-Ray  work. 

Few  dispensaries  have  even  limited  clinical  laboratory  facilities.  There 
are  probably  not  more  than  five  such  laboratories  in  use. 

One  private  ambulance  has  been  ordered  by  a  large  industrial  organiza- 
tion. The  inadequacy  of  ambulance  service  in  the  city  is  not  infrequently  a 
source  of  annoyance  and  even  danger  in  the  transfer  of  injured  workmen  to 
hospitals.  Especially  apparent  is  the  need  of  trained  ambulance  attendants. 
There  is  much  reason  for  believing  that  the  industries  of  Cleveland  could  be 
served  much  more  satisfactorily  than  at  present  by  a  centralized  ambulance 
call  system,  the  cars  of  such  a  system  to  be  operated  by  a  single  agency  or 
controlled  jointly  by  the  hospitals  of  the  city. 

Cost  of  Service 

Though  many  of  the  results  of  industrial  medical  service  must  be  reck- 
oned as  intangible,  there  are  ways  in  which  the  quality  of  service  which  is 
rendered  may  be  checked,  as  well  as  certain  effects  upon  employment  and 
insurance  costs  to  be  noted.  Through  these  means  may  be  obtained  an 
approximate  estimate  of  what  the  service  is  worth. 

It  is  more  simple  to  secure  accurate  figures  regarding  the  cost  of 
service.  There  are  several  plants  in  Cleveland  efficiently  applying  cost 
accounting  to  medical  departments  and  it  is  in  these  few  plants  alone  that 
there  is  definite  knowledge  of  the  total  outlay  for  medical  work.  Other 
firms  may  roughly  calculate  the  cost  by  guessing  at  the  value  of  medical 
supplies  purchased  or  on  hand  and  adding  to  that  amount  the  salaries  of 
personnel.  In  most  establishments  there  is  the  greatest  vagueness  regard- 
ing costs  of  service,  occasionally  combined  with  a  fanciful  exactness  regard- 
ing the  benefits  derived. 


534  Hospital  and  Health  Survey 

A  number  of  firms  stated  the  cost  to  be  in  the  neighborhood  of  five  dol- 
lars a  year  per  employe,  but  this  amount,  it  is  interesting  to  note,  is  rela- 
tively constant,  independent  of  the  size  of  the  plants,  nature  of  products, 
types  of  workers  or  the  extent  and  quality  of  service  rendered.  In  one 
large  establishment  the  cost  is  $10.92  a  year  per  employe  and  in  another 
$11.23.  Such  amounts  are  probably  not  excessive  at  the  present  time  if 
the  service  secured  is  comprehensive  and  of  a  high  order. 

Administrative  Relations 

The  ultimate  utility  of  a  medical  department  is  certainly  to  some  extent 
determined  by  the  place  which  the  department  occupies  in  the  industrial 
organization,  though  it  must  be  recognized  that  all  plants  are  not  conducted 
along  the  lines  prescribed  in  the  schematic  plan  of  administration.  If  a 
medical  department  is  to  develop  and  render  more  than  relatively  insignifi- 
cant service  it  must  have  at  its  head  a  responsible  executive  in  whom  is 
vested  suitable  authority. 

As  it  is  the  function  of  this  executive  to  conduct  operations  relating  to 
the  maintenance  of  a  healthy  staff  of  employes,  it  would  seem  reasonable  to 
select  for  the  office  a  properly  qualified  physician.  Not  infrequently  medical 
departments  are  administered  by  laymen  who  direct  the  activities  of  subordi- 
nate physicians,  a  practice  which  may  be  compared  to  the  employment  of 
a  good  foundryman  to  superintend  a  draughting  room  or  of  a  capable  pipe 
fitter  to  direct  the  tuning  of  a  piano. 

If  it  is  not  feasible  in  any  particular  industrial  organization  to  make 
the  medical  head  of  a  medical  department  directly  responsible  to  a  general 
executive,  he  should  at  least  have  authority  to  control  the  policies  and 
methods  within  his  own  field. 

In  Table  IV.  are  shown  the  administrative  relations  of  a  number  of 
industrial  medical  departments  in  Cleveland.  Reasonably  accurate  infor- 
mation regarding  fifty-six  organizations  has  been  tabulated.  In  certain 
establishments  the  duties  of  executives  are  not  well  defined  and  it  has  been 
necessary  to  determine  rather  arbitrarily  the  classification  of  the  adminis- 
trative relations  of  a  few  medical  departments. 

Under  "Administration"  are  included  medical  departments  responsible 
to  general  administrative  bodies  as  executive  boards  and  to  general  managers. 
"Production"  is  inclusive  of  factory  managers  and  superintendents.  "Em- 
ployment" includes  welfare  departments,  service  departments,  employment 
and  industrial  relations  managers.  "Claims"  includes  pension  and  acci- 
dent departments. 

Almost  half  of  the  medical  departments  classified  are  responsible  to  some 
form  of  employment  service,  78  per  cent  are  responsible  to  either  such  em- 
ployment service  or  to  general  administrative  officers,  while  only  17  per  cent 
are  responsible  to  production.  In  an  extensive  study  of  industrial  medical 
service  by  C  D.  Selby  in  1919,  41  per  cent  of  a  group  of  medical  departments 


Health     and     Industry  535 

were  found  to  be  responsible  to  production,  16  per  cent  to  labor  relations 
and  18  per  cent  to  administration. 

Though  conditions  within  individual  organizations  must  in  great  measure 
determine  the  relation  of  medical  departments  to  various  executives,  it  has 
appeared  that  the  best  developed  medical  services  have  been  in  departments 
headed  by  full-time  physicians  directly  responsible  to  general  administrative 
officers.  It  is  to  be  accepted  that  such  departments  must  cooperate  closely 
and  harmoniously  with  related  plant  activities.  If  no  full-time  physician 
is  employed  the  medical  department  may  well  come  under  the  supervision 
of  the  company  officer  or  executive  charged  with  labor  relations. 

The  heads  of  two  medical  departments  are  also  in  charge  of  the 
service  departments  of  their  respective  establishments.  Such  an  arrange- 
ment may  be  successful,  as  in  these  instances,  under  favorable  circumstances 
and  when  the  chief  surgeon  and  service  head  is  an  able  executive,  but  it  is 
not  one  to  be  commended  as  generally  applicable  or  desirable. 


MEDICAL  SERVICE  IN  NON-INDUSTRIAL  ESTABLISHMENTS 

Certain  mercantile  establishments  of  the  city  and  a  number  of  public 
utilities  have  developed  medical  services  which  are  so  similar  to  those  found 
in  industry  that  they  may  be  considered  as  within  the  scope  of  this  survey. 

In  Table  V.  of  the  appendix  is  set  forth  a  summary  of  the  statistical  find- 
ings covering  these  groups.  Contrary  to  the  condition  prevalent  in  manu- 
facturing establishments,  mercantile  medical  service  is  concerned  more  with 
the  health  of  employes  than  with  accidents.  It  affords  an  excellent  oppor- 
tunity for  a  demonstration  of  the  value  and  possibilities  of  medical  service 
as  distinguished  from  that  essentially  surgical. 

Medical  departments  have  not  to  this  time  been  developed  in  the  con- 
struction trades  though  the  health  and  accident  hazards  are  notable.  A 
beginning  has  been  made  in  Cleveland,  though  not,  however,  by  a  Cleveland 
construction  firm. 

There  are  in  Cleveland  about  twenty  thousand  workers  in  the  construc- 
tion trades.  For  many  of  these  the  work  is  arduous  and  hazardous  and 
demands  continued  exposure  to  inclement  weather.  Both  health  and  safety 
of  construction  labor  are  frequently  imperiled.  Small  injuries  are  numerous 
and  serious  accidents  common.  Extensive  construction  enterprises  involve 
the  housing  of  workmen  and  necessarily  special  problems  of  sanitation. 

Wages  in  the  construction  trades  are  high  and  the  time  lost  by  injured 
workers  is  a  costly  factor.  The  loss  incident  to  the  absence  of  men  from 
their  jobs,  sent  away  for  the  dressing  of  small  injuries  is  alone  great.  To 
this  must  be  added  the  cost  of  turnover  from  more  serious  accidents  and  from 
ill  health,  and  the  burden  of  numerous  fatalities. 


536  Hospital  and  Health  Survey 

There  could  be  developed  on  construction  jobs  medical  service  somewhat 
similar  to  that  of  the  army  in  the  field.  Portable  dispensaries  could  be  in- 
stalled where  needed,  suitable  light  equipment  provided  and  medical  and 
surgical  care  thus  made  available  for  sick  or  injured  workmen.  It  is  a  matter 
of  great  concern  to  individual  workers,  to  construction  firms  and  to  public 
health  authorities. 

MEDICAL  SERVICE  BEYOND  THE  PLANT 

Industrial  medical  departments  are  in  most  instances  established  and 
manned  to  furnish  surgical  care  for  industrial  injuries.  As  previously  indi- 
cated, there  has  been  relatively  slight  development  of  service  purposed  to 
care  for  the  health  of  operatives.  There  has  been  in  Cleveland  almost  no 
consideration  of  the  health  of  employes  beyond  the  confines  of  plant  prop- 
erty except  through  the  ministrations  of  a  few  visiting  nurses. 

It  is  of  course  difficult  to  determine  the  limits  of  the  social  orbit  of  an 
employe,  an  orbit  touching  many  interests,  work,  home,  church  and  recrea- 
tion. 

In  this  connection  it  is  of  interest  to  consider  the  curious  philosophy  of 
many  employers  who  rather  belligerently  assert  that  they  have  not  con- 
cerned themselves  with  the  health  of  their  employes  because  that  is  a  private 
affair;  that  if  the  men  received  good  working  conditions  and  good  wages 
they  receive  enough;  and  that  besides  there  are  in  the  city  men  who  have 
secured  training  for  the  medical  profession,  implying  that  in  consequence 
the  community  is  in  duty  bound  to  support  these  physicians  regardless  of 
their  merits.  Yet  the  same  employers  turn  to  show  proudly  their  company 
cooperative  stores  where  food  and  clothing  are  sold  at  cost,  or  at  a  trifling 
profit,  food  for  the  worker  and  for  his  family.  The  implications  in  this  case 
are  probably  that  food  and  clothing  are  not  to  be  regarded  as  private  affairs 
and  that  the  community  does  not  owe  storekeepers  a  living. 

The  employer  who  has  joined  with  his  employes  to  enhance  the  purchas- 
ing value  of  wages  by  sharing  in  the  operation  of  a  cooperative  store  has  but 
few  mental  steps  to  tread  till  he  faces  an  opportunity  to  secure  for  his  em- 
ployes that  which  is  as  necessary  in  their  lives  as  socks  and  canned  tomatoes 
—a  fair  chance  for  health  and  for  competent  medical  care  at  a  reasonable 
cost. 

It  should  be  possible  for  employers  and  employes  together  to  arrange  for 
the  establishment  of  industrial  dispensaries,  for  the  securing  of  medical  and 
nursing  personnel  and  for  the  conduct  of  such  dispensaries  upon  a  mutually 
satisfactory  basis.  A  dispensary  of  this  nature  might  be  limited  to  the 
full  medical  care  of  employes  or  might  increase  its  resources  to  include  the 
care  of  employes'  families.  The  extent  of  medical  and  nursing  service 
and  the  apportionment  of  cost  are  details  which  any  representative  fair- 
minded  body  could  readily  determine. 

There  are  in  Cleveland  at  least  two  mutual  benefit  associations  which 
participate  in  the  administration  of  plant  medical  service.     One  is.  in  its 


Health     and     Industry  537 

plan,  but  little  above  the  level  of  the  old-time  lodge  practice,  the  other  is  the 
most  promising  industrial  medical  service  in  the  city.  One  of  these  mutual 
benefit  associations  employs  a  physician  whose  office  is  provided  by  the  com- 
pany and  who  for  a  small  annual  sum  contributed  by  each  member  renders 
service  to  members  of  the  association,  services  necessarily  limited.  Em- 
ployes who  are  not  members  of  the  mutual  benefit  association  may  consult 
this  physician,  but  upon  a  fee  basis. 

In  the  other  organization  cited,  the  plan  is  to  render  comprehensive 
medical  service  of  the  highest  type,  employing  physicians  and  nurses  in  such 
numbers  as  may  be  required  to  insure  adequate  and  prompt  treatment  of 
employes.  It  is  contemplated  that  later,  service  shall  be  available  for  the 
members  of  employes'  families. 

INDUSTRIAL  MEDICAL  RECORDS 

There  is  such  a  thing  as  accumulating  useless  statistical  material,  of 
multiplying  indices  and  cross  indices,  just  as  there  is  the  considering  of  prob- 
lems by  guess  work  when  they  are  considered  at  all.  There  is  also  such  a 
thing  as  keeping  an  accurate  record  of  important  facts  and  of  summarizing 
the  data  so  made  available  in  such  a  manner  as  to  render  them  possible  of 
intelligent  interpretation.  It  is  a  safe  assumption  that  the  industries  of 
Cleveland  have  not  attained  their  present  eminent  position  by  the  universal 
application  of  the  sort  of  administrative  methods  which  are  generally  found 
in  their  medical  departments. 

There  are  several  establishments  in  Cleveland  in  which  essential  data 
regarding  injuries  and  illness  incurred  by  employes  are  recorded  and  the 
findings  so  tabulated  as  to  be  of  significance  and  great  value.  There  are 
numerous  establishments  with  thousands  of  records  so  inadequate,  confused 
and  inaccessible  that  they  are  practically  worthless;  and  there  are  others  which 
keep  no  records  worthy  of  mention,  yet  expend  a  total  of  many  thousands  of 
dollars  for  the  purpose  of  safeguarding  the  physical  welfare  of  employes. 

The  conditions  in  various  plants,  such  as  the  type  of  industry,  of  organ- 
ization, of  personnel  and  of  medical  service,  all  enter  into  the  consideration 
of  dispensary  records  and  forms  for  records.  It  is  probably  futile  and  not 
desirable  to  hope  for  general  adoption  of  any  uniform  record  system,  but 
there  are  a  few  minimum  standards  for  good  industrial  medical  practice 
just  as  there  are  for  good  hospital  practice.  Industrial  medical  records 
should  indicate  the  recognition  of  such  standards. 

It  is  not  within  the  province  of  this  report  to  set  forth  dogmatically  a  list 
of  standards  for  industrial  medical  records,  but  several  suggestions  may, 
however,  be  submitted. 

Records  concerning  individuals  should  be  so  filed  as  to  be  readily  acces- 
sible. This  may  entail  a  cross  index  by  name  if  records  are  filed  by  case 
number  or  shop  number.  Individuals  may  well  be  identified  by  name, 
number,  department,  nationality  and  address.  It  is  very  desirable  to  state 
the  actual  process  upon  which  an  employe  is  engaged. 


538  Hospital  and  Health  Survey 

Dates  of  injury,  illness,  treatment  and  discharge  should  be  set  down. 

Adequate,  though  possibly  brief  statements  should  be  made  regarding 
treatment,  such  as  dressings  or  medication.     Progress  notes  are  valuable. 

Accurate  diagnosis,  by  standard  nomenclature,  should  be  required. 
"Deferred"  and  "provisional"  diagnoses  should  be  supplemented  by  more 
accurate  opinions.     Condition  of  the  case  at  discharge  should  be  stated. 

Whether  the  record  form  be  a  card  filed  separately  or  in  a  folder  or  a 
sheet  bound  loose-leaf  fashion  or  filed  folded  or  flat  is  a  matter  for  each 
organization  to  consider.     Good  records  are  kept  in  any  one  of  these  ways. 

There  is  much  to  be  gained  by  filing  all  of  the  data  relating  to  an  indi- 
vidual in  one  place.  A  fairly  preva'ent  custom  is  to  make  out  a  new  form 
for  each  new  accident  or  illness  without  reference  to  the  previous  history  of 
the  individual  concerned.  In  many  instances  the  custom  can  be  well  justi- 
fied but  in  general  it  is  not  good  practice,  especially  in  regard  to  medical 
cases,  to  ignore  an  available  case  history. 

Ample  evidence  warrants  a  gentle  caution  against  indiscriminate  "elimi- 
nation of  paper  work."  A  certain  amount  of  paper  work  is  a  good  thing; 
it  saves  other  kinds  of  more  arduous  work. 

Industrial  medical  department  forms  are  of  practically  unlimited  variety 
as  to  shape,  filing  system,  purpose,  content  and  degree  of  usefulness.  The 
forms  collected  in  Cleveland  in  connection  with  this  survey  may  be  roughly 
classified  into  several  groups. 

(•a)  Forms  used  to  get  injured  or  ill  workers  from  the  plant  to  the  dis- 
pensary. They  include  passes  from  timekeepers  and  foremen,  with  or  with- 
out provision  for  record  of  time  elapsed  in  transit.  Some  include  space 
for  description  of  the  accident  incurred.  In  large  plants  it  may  be  found 
very  desirable  to  have  some  sort  of  a  check  on  the  time  consumed  by  employes 
in  coming  to  the  dispensary  and  in  returning  to  work.  An  ingenious  shirker 
can  occupy  several  hours  in  negotiating  the  short  distance  between  his  de- 
partment and  the  plant  dispensary.  It  is  to  be  remembered,  however,  that 
as  little  difficulty  as  possible  should  be  thrown  in  the  way  of  patients  which 
might  deter  them  from  making  free  and  prompt  use  of  the  dispensary.  In- 
fections and  prolonged  disabilities  are  the  penalties.  Official  statements  re- 
garding the  percentage  of  industrial  injuries  in  Ohio  which  have  become 
infected  and  regarding  the  influence  of  infection  on  the  production  of  perma- 
nent disability  offer  matter  for  serious  and  thoughtful  attention.  A  bulletin 
of  the  Industrial  Commission  of  Ohio  published  March  1,  1917,  stated  that 
of  73,525  industrial  accidents  for  which  awards  were  made  by  the  Com- 
mission for  the  year  ending  June  30,  1915,  infection  was  reported  in  connec- 
tion with  7,073  cases,  approximately  one-tenth  of  all  accidents.  Of  these 
7,073  cases  39  resulted  fatally,  161  in  permanent  partial  disability  and 
6,873  in  prolonged  temporary  disability. 


Health     and     Industry  539 

(b)  Forms  used  for  follow-up  to  insure  the  return  of  cases  needing 
continued  dressings  or  treatment.  These  include  hospital  passes  and  cards 
patterned  after  the  conventional  time  card,  used  in  racks,  one  for  a  case, 
and  "pulled"  by  the  dispensary  nurse  when  a  patient  has  received  his  ap- 
pointed treatment. 

(c)  Forms  for  case  records,  medical,  surgical,  dental,  ocular  or  for  spe- 
cial studies.  They  range  from  simple  cards  to  elaborate  forms  upon  which 
positive  findings  may  be  indicated  by  signs. 

(d)  Forms  for  physical  examinations.  Such  forms  vary  with  the  pur- 
pose for  which  physical  examinations  are  performed.  They  also  vary  with 
the  training  and  the  professional  hobbies  of  their  medical  authors. 

(e)  Forms  for  preliminary  and  final  reports  on  cases.  Usually  for  the 
purpose  of  informing  compensation  departments  regarding  the  nature  of 
injuries  and  the  progress  or  termination  of  cases.  Occasionally  include  a 
statement  of  professional  fees. 

(f)  Forms  for  periodic  reports  to  executive  departments.  They,  for  the 
most  part,  present  a  somewhat  curious  selection  of  data  and,  as  with  the 
case  of  many  other  forms,  are  of  unknown  executive  origin. 

Industrial. accidents  and  disease,  as  well  as  non-industrial  accidents  and 
illness,  are  important  and  costly  matters  concerning  employes  and  their 
employers,  affecting  as  they  do  not  only  the  well  being  and  income  of  indi- 
viduals but  also  operating  costs  through  lowered  morale,  absenteeism,  in- 
creased turnover,  lowered  production,  faulty  goods,  medical  care  and  insur- 
ance rates.  It  would  appear  to  be  a  subject  of  genuine  interest  to  progres- 
sive employers,  but  the  supposition  is  not  borne  out  in  the  records  of  many 
industrial  medical  establishments.  Even  though  ample  material  may  be  at 
hand  in  the  files  of  the  medical  departments  it  is  seldom  summarized  and 
tabulated  in  monthly  or  other  periodic  reports  in  such  fashion  as  to  furnish 
responsible  executives  with  sound  bases  for  comparative  judgments. 

For  example,  there  is  rarely  careful  discrimination  between  numbers  of 
individuals,  numbers  of  cases  and  numbers  of  dressings,  treatments  and 
visits.  There  is  rarely  a  comparative  statement  of  accident  and  illness  inci- 
dence based  upon  some  common  factor,  such  as  a  hundred  or  a  thousand 
full-time  workers.  A  relatively  small  department  of  a  plant  showing  ap- 
parently a  low  accident  incidence  may  in  fact  have  a  very  high  accident  rate. 
There  is  rarely  in  periodic  reports  a  differentiation  between  trifling  and  seri- 
ous accidents,  yet  more  important  than  the  frequency  rate  is  the  severity 
rate  indicating  the  time  lost.  This  may  be  illustrated  by  the  machine  trades 
in  which  the  number  of  accidents  causing  an  immediate  loss  of  time  of  less 
than  one  day  is  much  greater  than  the  number  of  serious  accidents,  perhaps 
ninety  to  ninety-five  per  cent  of  the  total.  Though  an  important  group  of 
injuries,  these  trivial  cases  are  not  reportable  to  the  Industrial  Commission 
and  do  not  figure  in  an  estimation  of  the  severity  rate.  Thus  the  machine 
trades,  having  a  fairly  high  accident  severity  rate,  have  a  still  higher  accident 
frequency  rate  because  of  numerous  accidents,  each  causing  disability  for  a 
short  period. 


■540  Hospital  and  Health  Survey 


These  more  accurate  reports  of  medical  department  data  do  not  demand 
the  attention  of  skilled  statisticians.  They  can  be  very  satisfactorily  com- 
piled by  industrial  nurses  or  clinic  clerks  with  possibly  occasional  supervision 
or  assistance. 

There  is  much  to  be  gained  from  the  general  adoption  of  some  uniform 
basis  of  reckoning  for  accident  and  sickness  statistics,  and  at  the  present  time 
there  appear  no  more  authoritative  standards  than  those  employed  by  the 
Bureau  of  Labor  Statistics  of  the  United  States  Department  of  Labor.  These 
include  the  standards  of  the  Committee  on  Statistics  of  the  International 
Association  of  Industrial  Accident  Boards  and  Commissions  regarding 
tabulable  accidents,  diseases  and  injuries;  what  shall  constitute  a  full-time 
worker;  the  computation  of  the  number  of  man-hours  worked  in  an  establish- 
ment and  a  scale  of  time  losses  for  weighting  various  industrial  accidents. 

According  to  these  standards  the  accident  frequency  rate  expresses  the 
number  of  tabulable  accidents  incurred  per  1,000  full-time  workers,  a  full- 
time  worker  being  one  who  works  ten  hours  a  day,  three  hundred  days  a 
year.  The  accident  severity  rate  expresses  the  number  of  days  lost  through 
tabulable  accidents  for  each  full-time  worker  per  year. 

The  utilization  of  this  method  of  tabulating  accidents  and  illness  would 
enable  executives  to  estimate  accurately  the  losses  from  these  sources  by 
departments,  by  processes,  by  various  time  periods,  by  day  and  night  shifts, 
by  nationalities,  or  in  other  ways;  would  enable  them  to  compare  their  losses 
with  other  similar  establishments  or  with  other  industries. 

Complete  and  recent  reports  of  accidents  in  Cleveland  have  not  been 
available,  but  a  bulletin  published  by  the  Industrial  Commission  of  Ohio  in 
1915  presents  an  analysis  of  reportable  industrial  accidents  occurring  in 
Cuyahoga  County  from  July  to  December,  1914.  Computations  based 
upon  the  figures  of  this  report  indicate  an  accident  frequency  rate  of  93.7 
accidents  per  1,000  workers  per  year,  and  an  accident  severity  rate  of  4.53 
days  lost  per  worker  per  year.     (Table  VL,  Appendix.) 

Through  the  courtesy  of  the  Industrial  Commission  advance  figures 
have  been  received  indicating  the  number  of  reportable  accidents  occurring 
in  several  groups  of  plants  located  within  selected  important  industrial 
areas  of  the  city  during  the  period  of  June  1,  1919,  to  November  30,  1919. 
The  industries  represented  were  quite  diversified,  though  for  the  most  part 
they  were  engaged  in  the  manufacture  of  metal  products.  These  figures, 
which  are  presented  in  Table  VII.  of  the  appendix,  indicate  for  a  total  of 
54,091  employes,  an  accident  frequency  rate  of  201.7  accidents  per  thousand 
workers  per  year,  and  an  accident  severity  rate  of  2.6  days  lost  per  worker 
per  year. 

Detailed  information  regarding  the  computation  of  accident  and  illness 
frequency  rates  and  severity  rates  may  be  obtained  from  the  Bureau  of  Labor 
Statistics  in  Washington. 


Health     axd     Industry  541 

ABSENTEEISM  DUE  TO  SICKNESS 

There  is  little  question  in  the  minds  of  those  deeply  concerned  with 
problems  of  industrial  health  that  the  greatest  present  need  in  this  field  is 
for  the  accumulation  of  accurate  and  extensive  data  regarding  absenteeism 
due  to  sickness  and  non-industrial  accidents.  It  is  not  always  easy  to  obtain. 
In  one  Cleveland  plant  unusually  satisfactory  reports  of  illness  are  obtained 
by  conditioning  a  portion  of  an  attendance  bonus  upon  the  prompt  report- 
ing of  cause  of  absence,  with  a  penalty  for  false  reporting.  In  another 
establishment  all  absentees  are  questioned  by  the  employment  department 
upon  their  return  to  work  regarding  illness  or  other  cause  of  absence. 

In  another  organization  all  employes  absent  over  a  certain  period  return 
through  the  medical  department.  Numerous  plants  obtain  much  valuable 
information  regarding  absenteeism  due  to  sickness  through  follow-up  person- 
nel, either  nurses  or  visitors  working  from  the  employment  offices.  It  is 
necessary  that  there  be  close  coordination  of  the  medical  and  employment 
departments,  and  of  importance  that  all  facts  secured  be  recorded  and  in- 
corporated with  the  records  of  individuals  in  the  medical  department. 

The  subject  is  one  which  has  been  rather  studiously  neglected  by  employ- 
ers who  customarily  state  that  non-industrial  sickness  is  not  of  their  concern 
and,  like  the  medical  care  of  such  illness,  is  wholly  a  private  affair  of  employes. 
This  is  questionable. 

In  recent  years  there  have  been  numerous  careful  investigations  into  the 
incidence  and  duration  of  absence  due  to  non-industrial  accidents  and  illness 
of  industrial  workers.  These  studies  have  shown  that  there  is  an  average 
time  loss  per  worker  usually  ranging  upward  from  six  days  per  year.  Seven 
days  of  lost  time  a  year  is  probably  a  conservative  estimate  for  all  industries. 
One  set  of  authoritative  figures,  based  upon  consideration  of  over  half  a 
million  workers,  places  the  time  loss  at  nearly  nine  days  per  year  per  worker. 

These  are  averages.  In  certain  trades  and  among  certain  nationalities 
the  loss  may  be  less  or  greater. 

If  to  a  time  loss  of  seven  days  for  non-industrial  accidents  and  illness 
there  be  added  an  estimated  loss  of  four  days  for  industrial  accidents,  there 
is  a  total  loss  among  the  industries  of  Cleveland  of  approximately  two  and 
a  fifth  million  days  a  year.  When  to  the  two  hundred  thousand  industrial 
workers  are  added  the  many  thousands  employed  in  the  public  utilities,  in 
mercantile  and  commercial  establishments,  in  the  construction  trades  and 
in  transportation,  there  is  a  most  impressive  total  of  time  loss,  with  its 
attendant  economic  loss  to  employes,  employers  and  the  community  as  a 
whole.  This  loss  is  not  of  wages'  and  production  alone  for  to  it  must  be  added 
the  burden  of  medical  and  social  care  placed  upon  numerous  individuals, 
physicians,  nurses,  hospitals  and  other  institutions. 

Estimates  of  actual  time  lost  must  be  supplemented  by  consideration  of 
the  intangible  but  noteworthy  losses  due  to  non-disabling  poor  health  and 


54-2  Hospital  axd  Health  Survey 

physical  and  mental  defects.  The  findings  of  the  examiners  of  draft  regis- 
trants in  191?  and  1918,  indicating  46S  men  per  thousand  with  important 
physical  or  mental  defects,  are  significant. 

It  is  reasonable  to  believe  that  these  evidences  of  sickness  and  accidents 
could  be  materially  reduced  by  applying  intelligent  and  simple  preventive 
measures  and  by  providing  a  better  mechanism  than  now  exists  for  the  care 
of  ill  health.  Even  were  the  burden  so  evenly  distributed  that  the  ardent 
champion  of  the  rights  of  the  individual  might  justly  argue  that  each  citizen 
bore  only  his  proper  share  and  so  should  be  responsible  as  an  individual, 
there  would  -till  be  ample  reason  for  developing  health  and  safety  education 
and  better  means  of  providing  medical  and  nursing  care. 

The  burden  is  not  evenly  distributed.  An  illustration  may  be  found 
in  Table  YIII.  of  the  appendix  where  are  compared  the  accident  incidence 
of  the  construction  trades  and  that  of  the  metal  trades  in  Cuyahoga  County. 
as  published  by  the  Industrial  Commission.  This  comparison  indicates  an 
accident  frequency  rate  in  the  construction  trades  over  twice  that  of  the 
metal  trades,  and  a  severity  rate  four  to  eight  times  as  great,  the  variation 
being  dependent  upon  various  assumptions  as  to  the  length  of  the  working 
day  for  workers  in  the  construction  trades. 

It  may  be  pointed  out  that  industry  presents  an  unparalleled  opportunity 
for  the  detection  and  remedy  of  defects,  for  the  observation  of  disease  in 
its  earliest  recognizable  stages  and  for  the  institution  of  measures  for  the 
treatment  of  such  disease.  In  no  other  way  than  at  work  are  so  many 
persons  brought  frequently  together  in  groups,  each  group  constituted  of 
individuals  living  much  the  same  sort  of  life  under  similar  conditions. 

It  is  recommended  by  the  Survey  that  industrial,  mercantile  and  other 
establishments  proceed  to  collect  data  regarding  the  incidence  and  nature 
of  sickness  and  accidents  among  employes  causing  absence  from  work.  This 
information  may  later  be  analyzed  with  great  profit  by  individual  organiza- 
tions, and  the  findings  of  individual  establishments  may  be  available  for 
consolidation  and  study  by  such  groups  as  associations  of  employment  man- 
agers, industrial  physicians  and  other  interested  agencies. 

PHYSICAL  EXAMINATIONS 

It  is  essential  for  efficient  public  health  control  that  there  be  knowledge 
of  the  community's  physical  constitution,  of  its  defects,  of  menaces  to  the 
public  health.  So  does  efficient  control  of  the  health  of  the  individual  rest 
upon  knowledge  of  the  physical  condition  of  the  individual.  It  is  of  course 
possible  without  this  knowledge  to  maintain  r-ertain  general  safeguards,  but 
they  are  of  necessity  inadequate  and  probably  frequently  misdirected. 

If  men  and  women,  and  especially  children,  are  to  labor  under  conditions 
which  do  not  work  undue  detriment  to  their  health  it  is  of  the  greatest  im- 
portance that  there  be  such  continued  observation  of  their  physical  state  as 
will  lead  to  the  prompt  institution  of  eorrective  measures  following  detection 


H  E.A  L  T  H       AND       INDUSTRY  548 

of  ill  effects.  This  can  no  more  be  done  without  initial  physical  examina- 
tions than  can  the  running  time  for  a  race  be  recorded  when  the  moment  of 
starting  is  not  noted. 

There  has  been  much  opposition  to  compulsory  physical  examinations 
exerted  by  organized  labor,  usually  the  expression  of  feeling  that  the  exami- 
nations might  be  made  an  instrument  for  discriminative  action  against  indi- 
viduals considered  by  employers  to  be  undesirable.  Without  doubt  physical 
examinations  have  been  at  times  the  occasion  of  injustices,  but  there  are  now 
thoughtful  men  in  the  labor  group  who  have  affirmed  their  belief  in  the  value 
of  physical  examinations  when  fairly  conducted  and  not  instituted  for  the 
elimination  of  defectives. 

Ohio  manufacturers  are  unusually  strengthened  in  their  position  of  being 
able  to  accept  practically  all  labor  applicants,  by  the  operation  of  the  Work- 
men's Compensation  Act  which  does  not  penalize  the  employer  of  a  defec- 
tive workman  who  incurs  by  accident  a  loss  to  a  single  remaining  paired 
member,  by  charging  against  that  employer's  compensation  account  a 
claim  for  the  total,  double  loss. 

The  findings  of  the  Survey  are  that  eleven  industrial  organizations  in 
Cleveland  conduct  compulsory  physical  examinations.  A  small  additional 
number  offer  optional  examinations.  It  is  of  importance  that  in  practically 
every  instance  the  only  bases  of  rejection  were  of  the  following  nature: 

(a)  Communicable  disease. 

(b)  Conditions  which  would  render  the  applicant,  if  employed,  liable  to  per- 
sonal injury  or  harm. 

(c)  Conditions  which  would  render  the  applicant,  if  employed,  a  menace  to 
the  health  or  safety  of  fellow  workmen. 

(d)  Unreasonable  lack  of  personal  cleanliness. 

The  second  and  third  reasons  for  rejection  have  not  been  frequently 
operative,  partly  because  of  the  labor  shortage  and  partly  because  in  large 
establishments  there  can  be  found  suitable  work  for  almost  any  defective. 

There  are  in  the  files  of  the  Survey  the  names  of  scores  of  firms  employing 
cripples  and  persons  handicapped  by  orthopedic  conditions,  deaf  and  dumb, 
partially  and  totally  blind  and  even  pronounced  and  recognized  mental  defec- 
tives. Selective  placement  is  not  always  made  with  desirable  precision,  but 
it  is  in  a  general  way  the  purpose  of  numerous  large  establishments. 

Ohio  law  requires  that  "no  person  suffering  from  or  afflicted  with  tuber- 
culosis, a  venereal  or  a  contagious  disease,  shall  be  employed  in  or  about 
any  part  of  a  restaurant  or  its  kitchen  or  handle  foodstuffs  or  products  used 
therein." 

In  the  course  of  this  study  but  one  establishment  among  the  leading 
hotels  and  restaurants  of  the  city  has  been  found  in  which  physical  examina- 


544  Hospital  and  Health  Survey 

tions  are  conducted,  and  that  a  department  store  restaurant.  Various 
managers  evinced  genuine  interest  in  examinations,  but  found  their  labor 
so. highly  mobile  and  scarce  as  to  deter  them  from  pursuing  the  matter. 

There  are,  however,  many  deaths  reported  from  tuberculosis  among 
cooks,  bakers,  stewards  and  waiters,  a  sufficient  number  to  suggest  that 
existing  active  cases  are  widely  distributed  among  the  members  of  these 
occupational  groups.  One  large  group,  of  food  handlers,  apparently  recog- 
nizing that  many  of  its  members  were  suffering  from  or  afflicted  with  com- 
municable disease,  appealed  for  the  cooperation  of  the  Survey  in  an  effort 
" looking  to  a  clearing  up  of  the  situation." 

It  would  appear  to  be  a  wide  field  of  endeavor  for  the  department  of  the 
State  Fire  Marshal,  to  which  department  the  Legislature  in  its  wisdom  has 
committed  the  administration  of  these  matters  pertaining  to  the  public 
health.  It  is  recommended  that  the  responsibility  for  the  maintenance  of 
health  among  food  handlers  in  restaurants  be  transferred  to  the  State  De- 
partment of  Health. 

Many  persons  are  daily  imperiled  because  of  defective  vision  or  other 
disability,  physical  or  mental,  in  those  who  operate  taxicabs  or  other  motor 
cars,  trucks,  cranes  and  elevators.  Few  of  such  operators  are  examined. 
The  safety  of  that  portion  of  the  public  which  boards  street  cars  and  rides 
therein  or  has  occasion  to  cross  tracks  is  daily  entrusted  to  a  large  corps  of 
men,  none  of  whom  are  examined  to  determine  their  freedom  from  infirma- 
ties  which  might  disqualify  them  for  certain  types  of  work. 

The  municipal  government  of  Cleveland  is  the  largest  single  employer  of 
labor  in  the  city,  having  on  its  payroll  approximately  10,000  men  and  women. 
As  such  its  responsibility  in  connection  with  the  maintenance  of  health  among 
working  people  is  not  only  a  great  one  but  very  immediate.  It  is  also  grossly 
neglected.     It  is  a  responsibility  shared  by  each  tax-paying  citizen. 

The  Survey  recommends  that  the  City,  through  its  Division  of  Health, 
provide  for  its  employes  an  initial  and  subsequent  periodic  physical  examina- 
tion with  such  medical  and  surgical  care  from  time  to  time  as  may  be  deemed 
necessary  and  advisable. 

It  is  wholly  reasonable  to  expect  of  the  city  government  a  service  for  its 
workers  comparable  with  the  best  medical  services  provided  by  large  indus- 
trial organizations. 


SPECIAL  SERVICES 

Industrial  Psychiatry 

As  one  of  the  outgrowths  of  careful  study  of  the  causes  of  industrial  unrest 
there  has  come  new  knowledge  of  psychology  as  applied  to  industry  and  even 
more  recently  the  beginnings  of  industrial  psychiatry.  Psychology  and 
psychiatry  are  terms  often  used  somewhat  carelessly  and  it  is  of  importance 
that  they  be  differentiated.     Psychology  may  be  defined  as  the  study  of 


Health     and     Industry  545 

states  of  consciousness,  but  is  ordinarily  limited  to  consideration  of  normal 
processes.  Most  psychologists  are  not  physicians.  Psychiatry  is  the 
study  of  abnormal,  pathological  mental  processes  and  conditions.  Most 
psychiatrists  have  been  trained  as  physicians. 

Military  surgeons  during  the  war  found  that  men  whose  mental  equip- 
ment was  not  such  as  to  permit  them  to  withstand  military  discipline  and 
routine  had  not  infrequently  checkered  industrial  histories,  having  held  many 
jobs  and  no  job  for  a  long  while.  Carefully  studied,  in  many  instances  these 
individuals  proved  to  be  of  psychopathic  type.  In  industry  they  had  prob- 
ably been  called  unruly,  inefficient  or  lazy. 

When  upon  deficient  mentality  are  thrown  the  burdens  of  fatigue,  of 
unhealthful  working  conditions,  of  real  or  fancied  injustices  and  of  economic 
uncertainties,  it  is  rather  to  be  expected  that  unrest  results. 

In  a  realm  of  science  so  beset  with  difficulties  as  is  psychiatry,  complicated 
in  an  industrial  environment  by  many  different  factors,  progress  will  likely 
be  slow,  but  the  development  of  this  field  warrants  earnest  consideration  by 
industry.  It  is  not  a  subject  to  be  approached  by  the  inadequately  trained 
or  by  the  casual  enthusiast. 

There  have  been  in  Cleveland  at  least  two  employers  who  have  made 
extended  use  of  psychometric  tests  and  over  such  a  period  of  time  as  to 
justify,  apparently,  the  continued  use  of  these  aids  to  employment  and  place- 
ment. In  neither  organization  have  the  tests  been  considered  as  other  than 
one  of  several  gauges  of  the  fitness  of  applicants. 

Industrial  Dental  Service 

The  public  in  recent  years  has  come  to  realize  in  some  degree  the  impor- 
tance to  health  and  self-respect  of  good  teeth  and  high  standards  of  mouth 
hygiene.  This  interest  has  been  reflected  in  the  development  in  industry  of 
dental  clinics  and  in  the  importance  which  is  attached  in  many  establish- 
ments to  the  care  of  the  teeth  of  employes.  While  a  casual  inspection  of  the 
teeth  is  a  part  of  every  reasonably  thorough  physical  examination,  several 
firms  have  installed  dental  chairs  and  employ  capable  dental  surgeons  to 
inspect  the  teeth  of  all  recent  employes.  Four  manufacturing  and  one  mer- 
cantile establishment  in  the  city  maintain  dental  service.  The  amount  and 
kinds  of  work  performed  vary  with  the  establishment  but  are  in  every  in- 
stance limited  to  nothing  more  costly  than  amalgam  fillings.  The  cost  is 
borne  either  entirely  by  the  employing  company  or  shared  by  the  employes 
who  pay  a  moderate  sum  for  materials  used. 

It  is  a  service  which  is  generally  enthusiastically  endorsed  by  the  organiza- 
tions which  have  installed  it  and  it  is  one  which  merits  wide  adoption. 

Industrial  Ocular  Service 

Several  industries  in  which  fine  work  demands  good  vision  have  found  it 
sound  practice  to  secure  for  their  employes  the  services  of  competent  oculists, 
not  only  to  determine  the  grade  of  vision  at  the  time  of  employment,  but  also 


546  Hospital  and  Health  Survey 

to  re-examine  workers  from  time  to  time  to  secure  by  glasses  proper  correc- 
tion of  refractive  errors.  Five  firms  maintain  oculists  for  work  of  this 
nature,  but  many  more  make  use  of  oculists  as  consultants  or  refer  to  them 
serious  eye  injuries.  In  far  too  few  instances  are  these  serious  eye  cases 
promptly  referred.  Inquiry  recently  made  indicates  that  a  large  portion  of 
industrial  eye  injuries  referred  to  ophthalmologists  had  been  previously 
mishandled.  Industrial  Commission  figures  for  the  state  at  large  have 
shown  that  eye  injuries  made  up  22  per  cent  of  the  cases  of  permanent  total 
disability,.  8.9  per  cent  of  cases  of  permanent  partial  disability  and  10.9  per 
cent  of  the  cases  of  temporary  partial  disability.  In  a  study  of  the  influence 
of  infection  upon  disability,  it  was  found  that  18  per  cent  of  the  cases  of  total 
or  partial  loss  of  vision  were  due  to  infection. 

The  neglect  of  vision  begins  early  in  many  industrial  plants.  The  Snellen 
chart  as  generally  used  is  one  of  a  number  of  false  gods  before  which  a  suc- 
cession of  company  officials  reverently  bow.  If  the  chart  is  veiled  in  dim 
obscurity,  the  almost  superstitious  regard  for  its  subtle  values  is  the  greater. 
Snellen  charts  hang  in  sunny  offices  or  in  half -lighted  basements;  some 
illuminated  at  the  top,  some  at  the  side;  some  by  glaring  light,  some  by 
moribund  filaments. 

There  are  in  Cleveland  a  number  of  able  oculists  who  are  greatly  interested 
in  industrial  eye  injuries  and  a  number  in  the  safeguarding  of  the  vision  of 
industrial  workers.     More  use  should  be  made  of  them. 

There  is  no  hospital  in  the  city  devoting  a  special  service  to  the  care  of 
eye  cases,  though  such  cases  are  occasionally  received  in  seven  general  hos- 
pitals. One  hospital  only  regards  certain  beds  as  belonging  to  the  eye  serv- 
ice, holding  four  beds  in  a  surgical  ward  for  this  purpose.  Five  hospitals 
have  magnets  for  the  removal  of  metallic  foreign  bodies. 

Cleveland  is  greatly  in  need  of  an  eye  hospital  and  the  almost  unanimous 
and  generally  emphatic  statements  of  the  oculists  of  the  city  regarding  the 
desirability  of  such  an  institution  warrant  a  favorable  response  from  the 
community. 

Tuberculosis 

In  an  industrial  population  as  large  as  that  of  Cleveland  it  is  certain  that 
there  are  a  considerable  number  of  cases  of  tuberculosis,  yet  in  the  establish- 
ments conducting  physical  examinations  the  number  of  cases  observed  is 
almost  negligible.  They  have  presumably  been  overlooked  either  because 
the  examinations  have  been  made  too  casually  and  hastily  or  because  they 
have  been  made  by  physicians  ill  qualified  to  examine  for  pulmonary  disease. 

Reports  of  the  municipal  Division  of  Health  offer  evidence  that  large 
numbers  of  industrial  workers  are  dying  of  tuberculosis.  As  no  data  are 
available  regarding  the  numbers  of  reported  cases  for  occupational  groups  or 
detailed  information  concerning  the  numbers  of  various  types  of  workers  in 
the  city,  no  fatality  or  mortality  rates  can  be  given. 


Health     and     Industry  547 

It  is  to  the  interest  of  those  afflicted  as  well  as  their  companions  at  work 
that  reasonable  measures  be  taken  to  identify  persons  with  this  disease  and 
to  assist  them  in  securing  proper  care.  The  incipient  cases  must  be  sought 
with  special  diligence,  for  in  such  cases  there  may  be  slight  evidence  of  ill- 
ness to  attract  the  attention  of  foremen  or  fellow  workers. 

The  physician  who  conducts  examinations  must  have  sound  knowledge 
of  chest  conditions  or  the  examinations  will  be  more  or  less  futile.  Not  all 
physicians  have  this  knowledge  and  while  it  is  in  a  sense  unfair  to  general- 
ize, it  is  safe  to  say  that  a  very  large  portion  of  the  surgical  group  of  the  pro- 
fession and  a  somewhat  smaller  portion  of  the  medical  group  know  little 
about  the  diagnosis  of  pulmonary  tuberculosis,  except  possibly  in  its  well 
advanced  stages. 

It  should  be  wholly  practicable,  however,  for  industry  to  make  frequent 
use  of  expert  consultants  who  might  review  groups  of  doubtful  cases  selected 
by  plant  physicians. 

The  opportunity  of  industrial  medical  services  to  cooperate  in  the  reduc- 
tion of  tuberculosis  is  a  very  valuable  one.  In  Cleveland  little  utilization 
has  been  made  of  it.  There  is  awakening  doubt  of  the  blissfulness  of  igno- 
rance in  regard  to  this  preventable  disease  which  is  alone  the  cause  of  a 
fifth  to  a  quarter  of  all  the  deaths  occurring  in  the  working-age  groups. 

Venereal  Disease 

The  activity  during  the  war,  of  the  United  States  Public  Health  Service, 
in  connection  with  its  extensive  program  for  the  combating  of  venereal  dis- 
ease unfortunately  did  not  stimulate  a  sustained  interest  in  the  subject 
among  employers.  There  are  probably  not  more  than  two  or  three  establish- 
ments in  Cleveland  in  which  venereal  disease  is  of  more  than  trifling  concern. 
Yet  Cleveland  is  not  a  community  distinguished  for  its  freedom  from  venereal 
disease  and  from  the  conditions  which  foster  it.  Nor  is  venereal  disease 
without  influence  upon  the  efficiency  of  working  people  and  upon  absentee- 
ism. Like  defective  vision,  and  tuberculous  lungs,  venereal  disease  has  been 
considered  a  personal  affair  of  the  worker,  another  inviolable  right  of  the 
individual. 

Though  much  of  the  traditional  prejudice  against  frank  and  honest  care 
of  venereal  disease  has  fortunately  passed,  it  is  still  in  practice  difficult 
either  to  secure  reporting  or  to  conduct  the  treatment  of  cases  in  industrial 
dispensaries.  There  are,  however,  no  insurmountable  difficulties  in  the  way 
of  tactful  and  straightforward  educational  work  with  advice  regarding  the 
accessibility  of  centers  for  diagnosis  and  treatment.  This  is  a  reasonable 
function  of  industrial  medical  service. 

The  Rehabilitation  of  Industrial  Cripples 

The  analogy  of  industrial  casualties  to  those  of  war  has  frequently  been 
pointed  out.     Though  this  has  long  been  a  matter  of  comment  and  there 


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550  Hospital  and  Health  Survey 

has  been  a  lively  interest  in  the  care  of  military  cripples,  govermental  agen- 
cies have  been  slow  to  evince  any  realization  of  the  economic  and  social 
folly  of  scrapping  the  cripples  produced  in  industry. 

There  has  been  scant  development  in  Cleveland  of  methods  for  the  treat- 
ment of  industrial  injuries  calculated  to  restore  the  injured  to  the  fullest 
possible  function  in  the  shortest  period  of  time  compatible  with  good  surgical 
practice.  There  has  been  limited  application  of  the  knowledge  gained  else- 
where in  recent  years  of  rehabilitative  methods  and  devices.  There  has  been 
in  the  community  and  in  its  leading  medical  centers  an  unfortunate  neglect 
of  orthopedic  surgery  with  consequent  loss  to  the  community  of  services  of 
a  special  nature  which  the  community  has  reason  to  expect.  Medical  cen- 
ters, teaching  and  others,  hold  a  public  trust. 

THE  SMALL  ESTABLISHMENT 

The  employer  of  less  than  two  or  three  hundred  workers  seldom  feels  justi- 
fied in  making  the  expenditures  necessary  for  a  plant  dispensary  installation 
and  for  the  maintenance  of  the  needed  personnel,  even  though  he  realizes 
that  his  employes  are  exposed  to  certain  hazards,  and  when  ill  or  injured  do 
not  receive  proper  care.  Considerations  of  economy  may  lead  him  to  aban- 
don his  desire  to  have  physical  examinations  of  applicants  for  employment, 
suitable  placement  of  the  less  fit,  prompt  and  efficient  medical  and  surgical 
attention,  visiting  nursing  service  and  health  supervision  in  his  plant. 

Ninety-four  per  cent  of  the  industrial  organizations  in  the  city  employ 
less  than  five  hundred  workers  each,  a  total  of  83,711.     (Table  I.,  Appendix.) 

Eighty -eight  per  cent  employ  less  than  200  each,  a  total  of  51,682. 

Eighty  percent  employ  less  than  100  each,  a  total  of  41,000. 

The  need  of  great  numbers  of  these  smaller  organizations  for  medical 
service  of  a  high  order  could  be  met  by  the  establishment  of  industrial  dis- 
pensaries at  various  points  in  industrial  districts,  carefully  selected  with 
regard  for  accessibility  from  the  plants  which  each  dispensary  would  serve. 

The  greatest  agglomeration  of  small  industrial  establishments  in  Cleve- 
land is  in  the  heart  of  the  city.  Within  a  radius  of  a  mile  of  the  Public  Square 
there  are  536  establishments  of  various  sizes,  employing  a  total  of  34,131 
workers.  Of  these  plants,  459  employ  less  than  100  each;  505  shops  employ 
less  than  200  each,  94.2  per  cent  of  all  establishments  in  the  area,  53  per  cent 
of  the  employes,  an  average  of  36  workers  per  establishment. 

Basing  an  estimate  upon  Industrial  Commission  figures  for  accidents 
occurring  in  plants  of  this  group,  there  is  an  annual  time  loss  for  industrial 
operatives  from  reportable  industrial  accidents  of  approximately  16,000  days, 
an  annual  total  of  22,400  accidents  of  all  grades;  and  a  time  loss  from  all 
accidents  and  illness  of  over  250,000  days.  Plant  medical  service  now 
reaches  less  than  8,000  of  the  operatives  in  this  area  through  eight  dispen- 
saries employing  a  total  of  ten  industrial  nurses,  two  full-time  and  four 
part-time  physicians. 


Health     and     Industry  551 

Quite  comparable  for  density  of  industrial  population  with  this  central 
area  of  the  city  is  the  region  about  Forty-fifth  Street  and  St.  Clair  Avenue. 
Within  a  radius  of  half  a  mile  of  this  point  are  employed  a  total  of  21,100 
operatives  in  114  establishments.  Of  these  plants,  71  employ  less  than  100 
workers;  89  employ  less  than  200,  being  77  per  cent  of  all  the  shops  in  the 
zone,  employing  22  per  cent  of  the  employes,  an  average  of  53  in  each  plant. 

The  estimated  annual  time  loss  for  industrial  operatives  from  reportable 
industrial  accidents  occurring  in  this  area  is  38,345  days.  There  is  an  esti- 
mated annual  total  of  accidents  of  all  grades  of  53,340,  with  a  time  loss  from 
all  accidents  and  illness  of  186,000  days.  Plant  medical  service  now  reaches 
a  little  over  7,000  employes  in  this  region,  through  eight  plant  dispensaries 
and  the  services  of  four  industrial  nurses  and  eight  part-time  physicians. 

The  area  of  density  of  industrial  population  extends  southward  from  this 
-region  about  Forty-fifth  Street  for  a  depth  of  three  or  four  miles  from  the 
lake  front.  Statistics  similar  to  those  presented  might  be  furnished  for  other 
circumscribed  areas  within  this  belt. 

Though  there  are  many  physicians  practising  within  this  large  zone  and 
in  other  parts  of  the  city  which  are  thickly  set  with  industrial  plants,  there 
is  at  present  no  industrial  dispensary  conducted  upon  an  essentially  coopera- 
tive basis. 

It  would  be  the  recommendation  of  the  Survey  that  the  general  adminis- 
tration of  such  a  cooperative  dispensary  as  has  been  suggested,  or  of  such 
dispensaries,  be  in  the  hands  of  a  commercially  disinterested  body  associated 
with  a  controlling  board  representing  employers,  employes,  physicians  and 
the  administrative  organization.  The  administration  might  be  the  respon- 
sibility of  a  general  hospital  or  of  any  one  of  several  recognized  and  trusted 
public  agencies  of  which  the  local  chapter  of  the  American  Red  Cross  may 
be  considered  an  example. 

Such  a  dispensary  should  be  self-supporting,  and  though  paying  salaries 
and  fees  sufficient  to  command  the  services  of  able  personnel,  should  not  be 
conducted  for  profit  in  the  customary  sense.  It  should  have  such  profes- 
sional supervision  as  would  assure  the  rendering  of  efficient  service. 

The  first  requirement  of  the  dispensary  would  be  the  care  of  industrial 
injuries,  with  surgeons  and  nurses  in  attendance  in  such  numbers  and  at 
such  times  as  might  be  needed.  It >  would  be  wholly  feasible,  however,  to 
extend  the  service  to  include,  if  desired,  physical  examination  of  applicants 
for  employment  or  of  employes,  mental  examinations,  medical  care  of  indus- 
trial and  non-industrial  sickness,  dental  service,  ocular  service  and  visiting 
nursing. 

The  cost  of  installation  and  maintenance  should  be  guaranteed  by  the 
industrial  establishments  participating,  but  it  would  in  part  be  returned  by 
the  Industrial  Commission  in  payments  for  service  rendered  under  the  Work- 
men's Compensation  Act. 


552  Hospital  and  Health  Survey 

If  established  for  a  group  of  two  thousand  employes  the  cost  of  main- 
tenance would  be  approximately  that  of  medical  service  in  a  single  plant 
employing  a  similar  number  of  workers,  between  five  and  ten  dollars  a  year 
per  employe,  though  of  course  the  amount  would  vary  with  the  range  of 
services  offered. 

INDUSTRIAL  HOSPITALS 

Cleveland  is  at  present  greatly  in  need  of  additional  hospital  beds.  With 
the  consequent  demand,  it  is  wholly  to  be  expected  that  serious  industrial 
accident  cases  are  frequently  peddled  about  the  hospitals  until  a  vacancy  is. 
found.  As  the  larger  part  of  such  cases  come  within  the  provisions  of  the 
Workmen's  Compensation  Act,  enabling  the  Industrial  Commission  to  pay 
for  certain  surgical  and  hospital  services,  and  as  the  amount  customarily  paid 
by  the  Commission  approximates,  in  most  instances,  half  or  less  than  half 
of  the  actual  cost  of  maintenance  in  hospital,  it  naturally  follows  that  a 
financially  pressed  institution  offers  the  injured  workman  its  minimum 
services  which  may  or  may  not  be  adequate. 

Xot  all  industrial  surgeons  hold  staff  positions  in  the  hospitals  of  the  city 
and  some  who  do  not  have  experienced  difficulties  in  performing  the  services 
for- which  they  are  employed  because  of  the  necessity  of  relinquishing  their 
responsibilities  to  the  hospitals  with  which  their  patients  are  placed. 

Inquiry  made  by  the  Survey  has  confirmed  an  impression  that  there  is  a 
field  in  Cleveland  for  one  or  more  hospitals  to  be  established  and  maintained 
for  the  care  of  industrial  cases  exclusively.  It  is  suggested  that  such  a  hos- 
pital could  best  be  administered  either  by  some  present  existing  hospital 
organization  in  which  there  is  general  confidence  or  by  a  board  of  control 
of  representative  character.  It  is  of  importance  that  the  professional  stand- 
ards of  such  an  institution  be  high  for  the  medical,  nursing  and  laboratory 
services,  and  that  the  hospital  be  open  to  all  qualified  industrial  physicians 
who  are  willing  and  able  to  practise  according  to  the  established  standards. 

Conducted  for  industrial  cases,  staffed  and  visited  by  skilled  industrial 
physicians  and  surgeons,  such  an  institution  should  make  available  a  type  of 
service  needed  but  not  at  present  found  in  the  city.  The  opportunities 
which  would  be  presented  for  attention  to  such  matters  as  ambulance  service, 
the  use  of  interpreters,  the  treatment  of  industrial  eye  injuries,  of  severe 
burns,  the  development  of  physiotherapy  and  other  rehabilitative  measures, 
would  alone  commend  the  project  to  many  persons  who  have  had  occasion 
to  follow  the  progress  of  cases  of  industrial  injury  under  existing  hospital 
conditions. 

THE  TRAINING  OF  INDUSTRIAL  PHYSICIANS  AND  NURSES 

It  has  been  evident,  perhaps,  that  industry  makes  certain  special  demands 
upon  the  physicians  and  nurses  who  serve  therein,  demands  with  which  most 
physicians  and  nurses  not  in  industry  are  unfamiliar  and  which  they  are  not 
trained  to  meet. 


Health     and     Industry  553 

There  is  a  rapidly  growing  need  for  the  services  of  industrial  hygienists, 
men  who  have  studied  the  toxic  effects  of  various  poisonous  substances  such 
as  are  now  used  in  many  industries;  men  who  are  competent  to  consider  such 
problems  as  those  of  the  effects  of  dusts  and  fumes,  of  ventilation,  of  illumi- 
nation, of  fatigue  and  of  factory  sanitation.  These  are  matters  which  most 
industrial  physicians  are  not  qualified  to  handle  intelligently  and  thoroughly 
though  they  may  from  experience  be  able  to  express  a  valuable  common  sense 
opinion. 

While  the  nurses  who  are  graduates  of  good  hospital  training  schools 
may  quickly  become  proficient  as  dispensary  nurses  they  are  by  no  means 
prepared  to  assume  readily  the  duties  and  to  comprehend  the  many  respon- 
sibilities which  are  now  properly  those  of  a  well  equipped  industrial  nurse. 

Special  instruction  is  required  for  the  rapid  training  of  industrial  physi- 
cians, hygienists  and  nurses,  and  it  is  to  be  hoped  that  the  existing  facilities 
of  the  Western  Reserve  Medical  School  may  be  expanded  and  supplemented 
to  permit  of  such  instruction  to  graduate  physicians  and  nurses  within  the 
coming  year.  Certain  portions  of  the  instruction  offered  to  physicians  might 
be  made  available  to  nurses  in  addition  to  courses  arranged  to  meet  their 
special  requirements. 

The  industries  of  the  Cleveland  district  would  unquestionably  profit 
greatly  by  the  establishment  of  such  a  school  of  industrial  hygiene,  not  only 
through  the  services  of  the  skilled  physicians  and  nurses  which  it  would  pre- 
pare for  their  employ,  but  through  the  development  of  research  facilities 
which  would  be  at  their  ready  disposal.  It  is  an  undertaking  deserving  of 
their  deepest  interest  and  of  their  support  and  cooperation. 

As  a  part  of  the  reorganized  hospital  and  dispensary  service  of  the  city 
there  is  contemplated  a  clinic  centrally  located  to  receive  emergency  cases 
and  to  offer  facilities  for  consultation.  In  connection  with  such  a  consulta- 
tion clinic  it  is  the  belief  of  the  Survey  that  there  should  be  established  an 
industrial  clinic  where  ailments  of  industrial  origin  might  be  thoroughly 
studied,  to  which  plant  dispensaries  might  refer  doubtful  cases  for  diagnosis 
and  to  which  workers  in  the  various  industries  and  trades  might  go  for 
authoritative  medical  advice. 

It  would  be  of  advantage  to  associate  this  clinic  closely  with  the  prospec- 
tive school  of  industrial  hygiene  in  order  that  each  might  profit  by  the  re- 
sources of  the  other. 


PUBLIC  HEALTH  AUTHORITIES  AND  INDUSTRIAL  HYGIENE 

The  Industrial  Commission  of  Ohio  is  vested  with  broad  powers  to  safe- 
guard the  health  and  safety  of  working  men  and  women.  It  possesses  con- 
siderable police  authority.  The  Division  of  Industrial  Hygiene  of  the  State 
Department  of  Health  is  endowed  with  certain  powers  of  inquiry  but  is  unable 
to  institute  obligatory  corrective  measures.  The  activities  of  this  division 
are  unfortunately  not  closely  correlated  with  those  of  the  Industrial  Commis- 


554  Hospital  and  Health  Survey 

sion  whose  inspectors  are  especially  concerned  with  questions  of  safety  and 
conditions  of  employment  other  than  those  relating  to  the  health  of  opera- 
tives. 

Adequate  as  are  the  powers  of  state  authorities  to  make  inquiries  and 
issue  orders  regarding  matters  pertaining  to  the  safety  and  health  of  indus- 
trial workers,  there  would  be  much  gained  to  the  industries  and  to  the  work- 
ingmen  and  women  of  Cleveland  through  the  establishment  of  a  Bureau  of 
Industrial  Hygiene  within  the  municipal  Division  of  Health.  It  could 
serve  in  an  advisory  and  consultant  capacity,  aiding  in  the  planning  of  fac- 
tories and  work  rooms  and  in  the  solution  of  problems  concerning  industrial 
hygiene.  Such  a  division  might  well  be  charged  with  the  conduct  of  medical 
service  for  the  municipal  employes  such  as  was  recommended  in  the  section 
of  this  report  relating  to  physical  examinations.  It  in  no  sense  need  conflict 
with  or  duplicate  with  the  activities  of  the  state  authorities. 

Cleveland  is  an  industrial  community;  the  greatest  common  interest  of 
her  people  is  in  her  industries  and  those  of  her  people  who  labor  therein  are 
the  life  of  the  city. 

The  future  of  Cleveland  depends  upon  the  well  being  and  the  happiness 
of  her  industrial  workers  and  to  secure  and  safeguard  their  health  is  the_vital 
task  of  industrial  medical  service. 


SUMMARY  OF  RECOMMENDATIONS 

It  is  the  recommendation  of  the  Survey — 

That  industrial  physicians  be  selected  with  regard  for  their  professional  and  execu- 
tive abilities;  that  they  be  remunerated  upon  a  basis  commensurate  with  the  amount 
and  character  of  service  expected  of  them;  that  they  be  not  permitted  to  combine  with 
their  official  duties  a  private  practice  among  the  company  personnel. 

That  industrial  nurses  be  chosen  for  professional  fitness  and  such  qualities  of  person- 
ality and  character  as  will  enable  them  to  fulfill  their  many  responsibilities. 

That  untrained  nurses  be  employed  only  under  competent  medical  or  nursing  super- 
vision. 

That  industrial  nurses  be  granted  such  authority  and  receive  such  support  as  may 
be  necessary  for  the  development  of  their  fullest  usefulness.  That  medication  by  nurses 
without  the  individual  or  standing  orders  of  a  physician  be  prohibited.  That  encourage- 
ment and  assistance  be  offered  industrial  nurses  in  their  efforts  to  maintain  contact  with 
progressive  movements  in  industrial  medicine.  That  visiting  nursing  be  considered  a 
normal  function  of  industrial  nurses.  That  industrial  nurses  be  rated  as  medical  person- 
nel. That  they  visit  sick  or  suspected  sick  and  be  not  employed  for  routine  absence 
follow-up  from  employment  departments. 

That  sufficient  clerical  personnel  be  employed  in  industrial  medical  departments  to 
free  physicians  and  nurses  for  professional  service. 

That  industrial  dispensaries  be  furnished  with  adequate  and  convenient  equipment 
which  need  not  be  elaborate. 


Health     and     Industry  555 


That  some  municipal  or  cooperative  industrial  service  be  undertaken  providing 
efficient  ambulance  transportation  of  sick  and  injured  to  the  hospital  from  industrial 
establishments . 

That  there  be  applied  to  industrial  medical  departments  efficient  cost-accounting 
systems. 

That  administrative  relations  of  industrial  physicians  permit  of  free  and  direct  ac- 
cess to  general  executives;  that  wherever  possible  physicians  and  not  laymen  direct  the 
activities  of  the  health  service  in  industrial  plants. 

That  employers  and  employes  together  arrange  for  the  establishment  and  maintenance 
of  cooperative  industrial  dispensaries. 

That  industrial  medical  records  conform  to  recognized  standards  of  adequacy  and  that 
they  be  filed  in  such  manner  and  so  summarized  as  to  make  possible  their  intelligent  in- 
terpretation. That  there  be  a  general  adoption  of  some  uniform  system  of  reckoning  for 
accident  and  sickness  statistics. 

That  there  be  study  of  absenteeism  due  to  sickness  and  non-industrial  accidents, 
among  the  employes  of  industry. 

That  physical  examinations  be  generally  adopted  as  prerequisite  to  employment,  not 
for  the  purpose  of  the  elimination  of  those  not  physically  fit,  but  for  guidance  in  the  proper 
placement  of  labor  applicants;  that  the  conditions  found  in  such  examinations  be  followed 
up  by  subsequent  periodic  examinations. 

That  responsibility  for  the  maintenance  of  health  among  food-handlers  in  restaurants 
be  transferred  from  the  department  of  the  State  Fire  Marshal  to  the  State  Department  of 
Health,  or  preferably,  if  possible,  to  the  Division  of  Health  of  the  City  of  Cleveland. 

That  there  be  compulsory  physical  examination  of  all  applicants  for  positions  as  oper- 
ators of  public  conveyances. 

That  the  municipal  government  maintain  within  the  Division  of  Health,  for  the  serv- 
ice of  all  its  employes,  an  adequate  health  service  or  bureau  which  shall  be  charged  with 
the  conduct  of  physical  examinations  of  applicants  for  civil  service  positions,  with  annual 
periodic  medical  examination  of  all  city  employes,  and  such  further  medical  service  as 
may  be'  deemed  necessary. 

That  there  be  a  study  of  the  problem  of  abnormal  mentality  among  industrial  workers, 
particularly  in  its  relations  to  vocational  guidance  and  unemployment. 

That  there  be  an  extension  and  development  of  industrial  dental  service. 

That  there  be  more  extended  use  made  of  the  services  of  skilled  oculists,  both  in  the 
care  of  industrial  injuries  and  in  the  conservation  of  the  sight  of  industrial  workers. 

That  there  be  more  extended  use  made  of  able  consultant  diagnosticians  in  connec- 
tion with  suspected  cases  of  tuberculosis. 

That  there  be  a  revival  of  interest  in  educational  work  directed  against  venereal 
disease. 


o.56  Hospital  and  Health  Survey 


That  there  be  proper  consideration  devoted  to  cases  of  permanent  disability  resulting 
from  industrial  injuries  with  particular  regard  to  the  development  of  methods  for  functional 
rehabilitation. 

That  there  be  developed  among  groups  of  small  industrial  establishments  some  form 
of  cooperative  dispensary  to  operate  under  the  joint  direction  of  employers  and  employes 
and  some  commercially  disinterested  organization.  That  there  be  established  one  or  more 
industrial  hospitals  exclusively  for  the  care  of  industrial  cases,  such  a  hospital  to  permit 
to  practice  any  industrial  physician  able  and  willing  to  meet  the  requirements,  which  should 
be  of  high  standard. 

That  there  be  developed  within  the  Western  Reserve  University  Medical  School  fac- 
ilities for  the  training  of  industrial  physicians  and  nurses.  That  there  be  established  in 
connection  with  some  central  dispensary  a  consultation  diagnostic  industrial  clinic. 

That  there  be  established  within  the  municipal  division  of  health  a  bureau  of 
industrial  hygiene. 


Health     and     Industry  557 

Women  and  Industry 

By  Marie  Wright 

INDUSTRY  has  become  interested  in  the  health  of  employes.  The  con- 
crete expression  of  this  interest  takes  different  form  in  almost  every 
establishment.  One  executive  enthuses  over  rest  periods,  another  shows 
every  visitor  the  immaculate  new  dispensary,  still  another  expatiates  upon 
the  benefits  to  be  derived  from  hot  food  at  noon.  Any  or  all  of  these  features 
may  contribute  to  the  well-being  of  the  working  force.  They  are  represen- 
tative of  various  activities  which  are  reasonably  those  of  industry,  not  to 
be  considered  mildly  extravagant  novelties,  but  essential  equipment  and 
services  giving  to  the  workers  the  opportunity  to  lead  a  healthful  life  at  work 
as  well  as  away  from  it. 

There  is  a  tendency  to  attribute  much  of  the  ill-health  of  working  people 
to  conditions  under  which  they  live  when  not  at  work.  Important  as  is  the 
relation  of  the  home  life  of  workers  to  their  health,  it  must  be  remembered 
that  the  character  of  the  home  life  is  largely  the  result  of  influences  growing- 
out  of  their  work.  Home  life  and  working  life  are  closely  inter-related.  The 
hours  of  work  determine  the  amount  of  leisure  for  improvement  and  appre- 
ciation of  the  home.  Wages  determine  to  a  large  extent  the  choice  of  neigh- 
borhood, of  building,  and  often  of  furnishings  and  food.  Visitors  to  the 
homes  of  working  people  are  at  times  dismayed  by  their  clutter  and  apparent 
lack  of  cleanliness,  but  these  conditions  are  not  necessarily  productive  of 
disease.  No  matter  what  the  home  of  an  employe  may  be,  his  employer 
has  the  responsibility  of  providing  a  work  place  reasonably  clean,  well  venti- 
lated, and  with  suitable  conveniences.  The  work  should,  if  possible,  be 
without  special  hazard,  but  where  there  is  danger  of  accident  or  illness  as 
a  result  of  any  process,  the  employe  should  be  informed  of  the  risk  and 
encouraged  to  guard  against  it  in  every  way. 

The  relative  susceptibility  of  men  and  women  to  fatigue  and  special 
hazards  is  a  matter  of  opinion  at  present  only  partially  substantiated  by  fact, 
but  the  employment  of  women  should  be  safeguarded  at  least  as  well  as 
that  of  men.  Because  of  the  important  relation  of  women  to  present  and 
future  generations,  it  is  generally  considered  that  they  should  have  especially 
favorable  surroundings  where  possible.  Another  reason  that  the  working 
environment  of  women  should  be  wholesome  and  their  occupations  health- 
ful is  that  they  are  less  likely  than  men  to  spend  their  margin  of  leisure  time 
in  healthful  recreation.  Many  girls  do  their  washing  and  ironing  and  make 
or  mend  their  clothes  in  the  evenings.  Married  women  and  widows  often 
work  harder  at  housework  than  they  do  during  the  day. 

Since  in  so  far  as  employers  endeavor  to  promote  the  health  of  employes 
they  are  promoting  the  public  health,  and  since  work  under  adverse  circum- 
stances is  one  of  the  greatest  detriments  to  health,  especially  for  women,  a 
study  of  the  work  which  women  are  doing  in  Cleveland  and  its  probable 
relation  to  their  health  has  been  included  in  the  general  survey  of  the  health 
situation  of  the  city. 


558  Hospital  and  Health  Survey 


In  order  to  learn  the  nature  of  the  various  occupations  in  which  women 
are  engaged,  visits  were  made  to  most  of  the  firms  known  to  employ  women 
in  considerable  numbers.  Realizing  that,  in  general,  conditions  in  small 
shops  are  not  as  good  as  in  large  ones,  it  was  nevertheless  considered  advis- 
able to  study  conditions  affecting  the  major  part  of  the  working  women. 
As  has  been  pointed  out,  in  Cleveland  seventy-nine  per  cent  of  all  industrial 
operatives  are  in  establishments  each  employing  over  one  hundred  persons. 
The  remaining  twenty-one  per  cent  are  distributed  throughout  a  large 
number  of  small  shops  averaging  about  thirty-three  employes  each. 
(Table  I,  Appendix.)  This  condition  is  even  more  apparent  among  mer- 
cantile establishments. 

During  February,  March,  and  April,  1920,  visits  were  made  to  seventy- 
nine  establishments  employing  a  total  of  22,906  women.  .  While  the  study 
was  primarily  concerned  with  the  industrial  field,  other  types  of  organiza- 
tions employing  women  were  found  to  have  problems  so  similar  that  a 
number  of  them  were  included.  Of  the  employes  in  the  establishments 
visited,  12,613  were  in  industrial  plants,  6,730  in  mercantile  establishments, 
1,458  in  organizations  of  public  service  and  2,105  in  public  utilities. 

There  are  no  recent  figures  available  as  to  the  number  of  women  gain- 
fully employed  in  Cleveland  except  those  in  the  Directory  of  Ohio  Manu- 
facturers (Industrial  Commission  of  Ohio,  1918),  and  as  the  employment 
of  women  has  fluctuated  since  this  report  was  issued,  its  figures  were  not 
found  accurate  in  all  cases.  Consequently  no  totals  can  be  given  for  the 
numbers  of  women  in  various  occupations  for  comparison  with  the  figures 
from  the  establishments  visited  in  the  course  of  the  Survey. 

Information  was  obtained  by  means  of  interviews  with  managers,  super- 
intendents, or  other  executives  in  touch  with  personnel  problems,  and  was 
usually  supplemented  by  a  visit  of  inspection  through  the  plants.  While 
information  so  obtained  is  general  and  often  not  exact,  the  collection  of 
repeated  impressions  by  an  impartial  observer  is  so  far  almost  the  only 
means  of  judging  the  subtle  factors  which  enter  into  the  making  of  a  good 
place  to  work.  While  the  attitude  of  executives  varied,  there  was  in  general 
a  manifest  interest  in  the  well-being  of  employes  and  an  appreciation  of 
the  fact  that  knowledge  of  methods  for  maintaining  and  improving  the 
health  of  workers  should,  by  the  interchange  of  ideas  and  experiences,  be 
made  available  for  all  industry.  The  value  of  health  is  appreciated  at  a 
time  when  labor  is  scarce. 

INDUSTRIAL  ESTABLISHMENTS 

It  is  not  a  new  thing  for  women  to  be  in  industry.  The  war  focussed  so 
much  attention  upon  women  who  were  doing  the  work  of  men  in  factories 
that  it  is  frequently  forgotten  that  women  have  had  a  place  in  Cleveland's 
nut  and  bolt  shops  and  other  plants  making  small  metal  products  since 
those  concerns  were  first  established — a  matter  of  thirty  to  forty  years.  In 
the  textile  and  knitting,  garment  and  candy  trades,  women  have  always 
been  a  predominant  labor  element. 


Health     and     Industry  559 

During  the  war  more  women  went  into  factories  than  had  ever  done  so 
before.  Increased  demand  for  the  regular  products  of  essential  industries 
enabled  manufacturers  in  those  branches  to  hold  and  increase  their  forces, 
while  women  for  the  making  of  munitions  were  usually  recruited  from  the 
"non-essential  industries"  or  from  that  large  body  of  women  who  had  not 
worked  before  but  whose  patriotism  enabled  them  to  undertake  successfully 
the  new  and  often  heavy  work.  Most  of  these  women  left  the  factories  upon 
the  completion  of  government  orders  and  have  not  returned.  The^  "non- 
essential industries"  have  reclaimed  many  of  their  former  employes,  and 
by  now  readjustment  is  about  complete. 

There  are  a  few  factories  which,  as  a  result  of  their  war  experience,  have 
continued  to  employ  women  although  they  had  not  done  so  before.  In  the 
six  factories  where  it  was  learned  that  this  was  the  case,  six  hundred 
women  are  employed.  Two  of  these  factories  have  continued  to 
employ  the  women  who  started  to  work  there  during  the  war,  but  as  they 
drop  out  men  are  hired  in  their  places,  and  consequently  the  number  of 
women  is  dwindling.  In  another  plant  there  are  very  few  women  com- 
pared with  the  number  employed  during  ,the  war,  and  the  women  are  giving 
up  machine  work  for  bench  work  of  a  light  type. 

Within  the  past  two  years  there  have  been  established  four  new  factories, 
employing  a  total  of  698  women.  Neither  the  retention  of  women  in  plants 
which  had  not  formerly  employed  them,  nor  their  employment  in  new  fac- 
tories, is  sufficient  to  account  for  the  present  shortage  of  female  labor.  The 
checking  of  immigration  and  the  return  of  many  foreign  workers  to  Europe, 
is  a  partial  cause  of  a  general  shortage  of  both  men  and  women.  The  fact 
that  wages  for  men  are  higher  than  ever  before  means  that  many  women 
do  not  have  to  work  now  as  they  did  formerly,  and  in  many  cases  this  new 
independence  has  apparently  resulted  in  an  unfortunate  attitude  toward 
work,  with  a  greater  absenteeism  and  a  tendency  to  float  from  job  to  job. 

In  the  face  of  this  labor  shortage  the  cry  for  increased  production  has 
aroused  feverish  efforts  on  the  part  of  employers  to  get  help  in  one  way  or 
another.  The  alluring  advertisements  of  "Help  Wanted"  contribute  to  the 
prevailing  unrest,  and  the  readiness  to  try  a  new  job  upon  the  slightest  dis- 
satisfaction with  the  old.  Applicants  from  such  sources  do  not  prove  satis- 
factory. Instead  of  advertising,  several  firms  are  now  paying  a  bonus  to 
employes  who  bring  in  friends  who  will  continue  to  work  for  a  certain 
period  of  time,  recognizing  the  principle  that  a  satisfied  employe  is  the 
best  advertisement  in  the  labor  market. 


The  Metal  Trades 

The  largest  group  of  industrial  establishments  studied  was  in  the  so- 
called  metal  trades,  where  the  product  varies  from  a  small  piece  of  machined 
steel  to  an  assembled  oil  stove  or  an  electric  lamp.  3,691  women  were 
employed  in  the  twenty-three  plants  visited.  The  operations  included  bench 
work  and  assembly,  as  well  as  operating  such  machines  as  drill  presses,  punch 
presses,  screw  machines,  lathes,  and  a  variety  of  machines  adapted  for  special 
processes. 


560  Hospital  and  Health  Survey 

Most  of  the  work  is  not  heavy,  and  the  girls  are  instructed  to  lift  not 
over  ten  to  fifteen  pounds,  although  they  not  infrequently  disobey  this 
rule.  Where  girls  are  on  machines  requiring  gear  shifts,  special  efforts  have 
been  made  to  favor  ease  of  operation.  However,  there  is  considerable  effort 
in  the  running  of  any  screw  machine  or  lathe,  and  in  general  it  has  seemed 
better  practice  for  men  to  do  that  work. 

Punch  presses  and  drills  are  usually  guarded,  and  relatively  few  acci- 
dents to  women  have  been  reported.  Although  no  data  are  available  as  to 
the  carefulness  of  women  in  operating  machines  compared  with  men,  there  is  a 
prevalent  impression  that  they  are  more  careful  than  male  operatives  and 
that,  freely  accepting  risks  of  operation,  they  make  little  complaint  when 
injured.  Nineteen  of  these  twenty-three  establishments  provide  medical 
service. 

Bloomer  uniforms  are  required  in  five  plants  and  are  optional  in  several 
others.  The  uniform  has  fallen  into  disfavor  since  the  war,  and  effort  is  needed 
to  enforce  its  use  at  machine  work  and  to  maintain  any  degree  of  uniformity 
and  safety  by  the  avoidance  of  jewelry,  fluffy  collars  and  ties.  High-heeled 
shoes  for  standing  work  should  also  be  opposed  where  possible  by  making  it 
easy  for  the  women  to  get  sensible  working  shoes  reasonably  priced.  Individual 
steel  lockers  are  provided  in  twelve  plants  and  hooks  in  dressing  rooms  in 
most  of  the  others.  The  increased  feeling  of  well-being  and  self-respect  of 
the  worker  who  changes  from  street  clothes  to  working  clothes  and  back 
again  is  worth  emphasizing  by  employment  or  service  departments. 

Although  several  of  the  plants  have  physical  examination  for  men,  only 
one  organization  was  found  to  give  to  girls  anything  which  might  properly 
be  called  a  physical  examination.  There  seems  to  be  little  realization  of  the 
impossibility  of  judging  by  appearance  as  to  a  girl's  fitness  for  fatiguing  work. 
With  a  high  degree  of  conscientiousness,  several  employment  departments 
have  taken  a  timid  attitude  in  this  matter.  The  fear  that  girls  will  object 
to  physical  examinations  properly  conducted  is  with  slight  foundation,  as 
they  are  in  general  use  in  similar  establishments  elsewhere,  and  where  used 
in  Cleveland  meet  with  little  or  no  opposition.  If  physical  examinations 
are  conducted  on  a  reasonable  basis  of  rejection  and  if  their  purpose  is 
frankly  explained,  it  is,  as  a  rule,  only  the  undesirable  worker  who  will  raise 
any  objection. 

The  dirt  and  grease  of  machine  shops,  which  in  the  minds  of  many  people 
render  them  unsuitable  places  for  the  employment  of  women,  are  in  fact 
not  objectionable  if  there  are  provided  proper  washing  facilities  and  oppor- 
tunity to  use  them.    Such  facilities  must  include  hot  water. 

The  noise  and  vibration  from  different  kinds  of  machinery  are  of  rela- 
tively greater  importance. 

There  is  about  many  machine  shops  a  wholesome  attitude  toward  work 
which  is  very  appealing  to  the  sturdy,  independent  type  of  girl,  frequently 
encountered  in  this  industry.  Many  girls  who  worked  in  munitions  factories 
testified  that  they  had  never  been  so  happy  before. 


Health     and     Industry  561 

Tables  XI  and  XII  of  the  appendix  present  the  findings  regarding  hours 
and  starting  rates  for  the  various  industries  studied.  The  usual  working  day 
for  women  in  the  metal  trades  is  from  seven  to  half  past  four.  Although 
piece-work  is  prevalent,  a  certain  minimum  daily  wage  is  guaranteed  in 
fifteen  plants,  while  three  others  pay  a  guaranteed  minimum  wage  for  the 
learning  period.  There  is  little  or  no  seasonal  variation,  but  the  supply  of 
work  frequently  varies  with  orders. 

Some  factories  employ  American  girls  almost  exclusively,  others  only 
foreign  born  or  those  of  foreign  parentage.  Usually  all  nationalities  are 
represented,  but  for  heavy,  dirty  work  the  foreign  women  of  peasant  type 
are  in  greatest  demand.  Colored  women  are  employed  in  two  plants  in  con- 
siderable numbers. 


Textile  and  Knitting  Mills 

The  female  operatives  of  the  textile  and  knitting  trades  constitute  an 
important  group  of  working  women,  numbering  4,642  in  the  eleven  estab- 
lishments visited.  The  knitting  mills  seem  in  almost  every  case  to  be  work- 
ing beyond  normal  capacity.  In  a  number  of  instances  mills  were  working 
under  great  pressure  upon  goods  for  delivery  a  year  hence.  Supposedly  as 
a  result  of  the  increased  activity,  work-rooms  were  cluttered  with  piles  of 
unfinished  work,  and  there  were  evidences  of  poor  factory  housekeeping. 

The  numerous  exposed  overhead  belts  furnishing  power  to  circular 
knitting  machines  seem  to' be  an  unnecessary  accident  hazard  for  the  opera- 
tives who  are  constantly  obliged  to  move  about  under  them. 

The  brightly  colored  fluff  from  the  yarn  is  everywhere  on  the  machines, 
and  at  times  adheres  noticeably  to  the  faces,  arms,  and  hair  of  the  girls. 
Occasionally  they  develop  sore  hands  or  arms,  said  to  be  caused  by  the 
dyes.  In  one  plant  mention  was  made  of  the  numerous  sore  throats,  but  they 
were  attributed  to  "late  hours  and  dances."  As  only  four  plants  in  this 
group  have  medical  service,  and  only  one  employs  a  physician,  there  has 
been  little  definite  study  of  health  problems  within  this  industry. 

The  working  hours  are  forty-nine  and  one-half  or  fifty  in  all  but  two 
establishments,  as  may  be  seen  in  Table  XI.  The  working  day  is  usually 
seven-thirty  to  five  or  five-fifteen.  Most  of  the  women  employed  are  either 
foreign-born  or  are  of  Hungarian,  German,  Austrian,  or  Polish  parentage. 
Although  most  of  them  are  between  twenty  and  thirty  years  of  age,  they  are 
of  a  mature  type,  appearing  much  older. 

The  Garment  Trades 

In  the  seven  garment  factories  visited,  2,700  women  are  employed. 
Much  of  the  work  is  power-machine  operating,  with  the  usual  varieties  of 
finishing  work.  The  great  problem  of  the  garment  trades  is  the  regulariza- 
tion  of  employment,  or  elimination  of  seasonal  variations  in  production. 
As  a  result  of  the  attention  which  has  been  given  to  this  problem,  three 


562  Hospital  and  Health  Survey 

firms  reported  that  they  had  work  steadily  throughout  the  year.  One  re- 
ported work  for  at  least  forty -eight  weeks.  Two  large  establishments  operate 
through  a  .fifty -week  year,  and  of  the  remaining  two  weeks,  one  week  is 
"layoff"  and  one  may  be  vacation  with  pay.  Another  firm  has  a  fifty-one-week 
year,  and  the  whole  factory  closes  for  one  week  of  vacation.  As  is  shown  in 
Table  XI,  weekly  hours  are.  forty-four  or  forty-three  and  three-quarters,  in 
all  but  two  shops,  where  they  are  forty-seven.  One  plant  uses  an  allotment 
system — workers  going  home  when  the  day's  task  is  completed,  and  seldom 
working  even  the  possible  forty -four  hours.  Two  firms  work  an  eight  and 
three-quarter-hour  day  five  days  a  week,  with  a  full  holiday  Saturday. 
Another  firm,  after  trying  the  same  plan,  is  strongly  in  favor  of  the  eight- 
hour  day  and  a  half-holiday  on  Saturday. 

In  the  ladies'  garment  trade  the  wages  are  usually  set  by  the  union  wage 
scale  agreement,  under  which  the  minimum  is  $14  per  week.  Comparative 
starting  rates  may  be  found  in  Table  XII. 

Bohemians,  Italians  and  Hungarians  are  the  leading  nationalities  in  each 
of  several  factories  visited,  with  various  Slav  peoples  also  represented.  In 
several  factories  there  are  more  than  one-third  or  one-half  American  born. 
Two  factories  will  hire  no  one  who  does  not  speak  English. 

The  use  of  routing  systems  and  time  study  has  made  the  modern  garment 
factory  a  very  different  place  from  the  old-style  tailor  shop. 

Candy  Factories. 

Candy  factories  are  as  a  rule  relatively  small  establishments.  The  six 
visited  had  a  total  of  371  women  employes.  The  demand  for  candy  is 
seasonal,  and  there  seems  to  be  no  way  to  regularize  its  manufacture,  since 
it  should  be  sold  within  a  short  time  after  it  is  made,  unless  stored  under 
most  favorable  conditions.  Two  firms  reported  that  they  never  laid  off 
any  help,  as  their  forces  automatically  decreased  in  slack  seasons  when  workers 
who  left  were  not  replaced.  Most  of  the  girls  were  American  born,  and 
as  a  group  were  young,  although  older  women  are  used  for  sorting  and  other 
work  since  girls  have  become  scarce.  As  little  skill  is  required,  except  that 
natural  to  young  fingers,  there  are  many  floaters  who  find  in  the  busy  seasons 
of  the  candy  trade  the  brief  employment  which  satisfies  them.  Such  workers 
are  apt  to  be  careless  about  their  work,  and  their  persons,  and  require  care- 
ful supervision,  especially  in  the  making  of  a  food  product.  This  super- 
vision was  generally  found,  but  several  establishments  could  well  improve 
their  standards  of  cleanliness  as  well  as  their  equipment  for  the  comfort  of 
employes. 

Miscellaneous  Industrial  Establishments 

Of  those  establishments  listed  as  miscellaneous,  some  of  the  paper-box 
factories  are  small  but  quite  progressive  in  policy. 

Two  tobacco  factories  revealed  an  interesting  general  situation.  The 
tobacco  industry  of  Cleveland  finds  itself  on  the  decline  largely  because  of 


Health     and     Industry  563 

scarcity  of  skilled  labor.  In  Cleveland  no  American  girls  and  very  few  young 
foreign  girls  will  work  on  cigars.  As  a  result  the  workers  are  practically 
all  foreign  born  and  mostly  foreign-speaking,  and  with  the  realization  of 
their  dwindling  numbers  have  become  very  independent.  One  executive 
said  that  his  plant  is  kept  open  fifty  hours  a  week  for  the  convenience  of  his 
employes,  but  none  of  them  work  so  long,  as  they  come  and  go  at  their 
pleasure.  Several  firms  which  began  business  in  Cleveland  have  found  it 
necessary  to  take  most  of  their  work  elsewhere,  and  now  have  large  tobacco 
factories  in  New  York,  Pennsylvania  and  Texas.  These  are  said  to  be 
model  factories  as  the  workers  speak  English  and  appreciate  the  good  work- 
ing conditions  provided.  The  firms  apparently  realize  that  the  Cleveland 
factories  could  be  made  both  mOre  attractive  and  more  healthful.  Learning 
to  make  cigars  requires  several  weeks,  during  which  time  most  of  the  material 
handled  is  waste  and  cannot  be  reclaimed.  The  cost  of  teaching  a  new  maker 
is  said  to  be  $350,  even  at  the  starting  rate  of  $12  a  week.  When  $15  and 
$16  a  week  is  offered  to  an  unskilled  girl  in  other  industries,  there  is  little 
incentive  for  her  to  learn  a  difficult  trade,  even  with  the  promise  of  high 
piece-work  earnings  later. 


General  Observations  on  Industrial  Establishments. 
Hours  of  Work 

Reference  has  already  been  made  to  the  weekly  hours  in  several  trades. 
(Table  XL)  In  the  course  of  the  Survey,  little  overtime  work  was  reported. 
Only  ten  firms  admitted  that  they  had  any  overtime  for  women,  and  that 
was  said  to  be  only  occasional  or  optional.  It  seems  probable  that  over- 
time is  more  frequent  in  clerical  work  than  in  industry. 

While,  to  the  knowledge  of  the  Survey,  regular  rest  periods  are  arranged 
for  in  only  one  factory,  there  are  four  establishments  in  which  women  are 
allowed  fifteen  minutes  about  nine  o'clock  in  the  morning  for  the  purpose 
of  eating  part  of  their  lunch.  This  is  an  interesting  acceptance  of  the  custom 
of  many  women  who  go  to  work  with  little  or  no  breakfast,  and  consequently 
feel  the  need  of  food  before  the  regular  lunch  hour.  Another  establishment 
has  two  five-minute  rest  periods  which  are  optional,  and  consequently  not 
extensively  used.  One  firm  had  discontinued  rest  periods  during  the  day 
but  dismissed  all  employes  twenty  minutes  before  the  accustomed  closing 
hour,  granting  pay  for  the  full  day.  Rest  periods  may  be  of  additional  value 
as  a  means  of  improving  ventilation  by  open  windows.  Many  workers 
object  to  fresh  air  if  it  must  be  admitted  near  them.  Few  people  fail  to 
appreciate  a  room  full  of  fresh  air  replacing  what  has  been  vitiated,  especially 
when  there  are  present  fumes  or  odors  incident  to  an  industrial  process. 
It  is  probable  that  in  many  factories  where  the  work  is  monotonous  and 
exacting,  much  might  be  gained  by  instituting  rest  periods.  Both  before  and 
after  the  introduction  of  such  a  measure,  it  is  important  that  careful  obser- 
vation be  made  of  the  physical  condition  of  workers  as  well  as  of  production 
rates. 


564  Hospital  and  Health  Survey 

Earnings 

It  was  hoped  at  first  that  figures  might  be  received  from  payrolls  show- 
ing actual  earnings  of  a  group  of  workers  over  a  suitable  period  in  order  to 
obtain  a  fair  conception  of  the  relation  of  earnings  to  the  cost  of  living  and 
the  opportunity  for  health.  This  was  not  found  practicable,  however.  Wage 
rates  are  misleading,  and  as  some  are  by  the  day  and  others  by  the  hour  or 
piece,  comparison  is  difficult  and  often  unfair.  The  starting  rates  reported 
have  been  tabulated  in  Table  XII.  Some  establishments  raise  the  rate  at 
the  end  of  the  first  week,  some  after  two  weeks  or  a  month,  and  in  many 
cases  the  rate  stands  until  the  piece-work  earnings  are  higher,  which  may 
be  in  a  few  days  or  a  matter  of  months.  Estimated  averages  for  the  various 
establishments  and  their  maximums  are  obviously  so  inaccurate  in  most 
cases  that  they  have  not  been  presented  in  this  report.  In  several  cases 
where  averages  of  actual  earnings  have  been  made  and  analyzed,  the  results 
have  been  at  variance  with  previous  estimates — additional  evidence  of  the 
futility  of  accepting  approximate  figures  regarding  actual  earnings  even  from 
persons  familiar  with  establishment  pay-rolls. 

A dditional  Ben efi is — Cafeteria 

Practically  all  industrial  establishments  provide  either  a  cafeteria  or  a 
lunch-room.  The  cafeteria  may  serve  a  full  meal  approximately  at  cost  or 
may  provide  food  to  supplement  the  lunch  brought  by  workers.  Most 
plants  arrange  that  coffee  or  other  hot  drinks  may  be  secured  free  or  at  slight 
expense.  In  six  plants  the  employes  eat  in  work-rooms,  in  certain  instances 
the  company  providing  coffee.  Several  of  these  establishments  have  rooms 
which  are  called  lunch-rooms,  probably  in  the  hope  that  they  may  thus 
fulfill  the  requirements  of  the  law.  The  benefit  of  a  change  of  environment 
together  with  good  food  at  meal-time,  is  generally  recognized,  and  many 
factories  are  planning  better  equipment  in  new  buildings  which  they  have 
in  prospect. 

Cooperative  buying  is  another  way  of  increasing  the  purchasing  power 
of  wages,  which  has  been  undertaken  in  several  Cleveland  factories  with 
much  success.  Group  life  insurance  carried  by  the  company  is  an  advantage 
offered  by  many  firms.  Only  eight  industrial  establishments  reported  benefit 
associations  or  some  form  of  sickness  insurance  for  women  employes. 
Several  other  firms  have  benefit  associations  but  women  are  excluded  from 
membership,  the  reasons  not  always  being  clear. 

Recreation 

In  twenty-one  establishments  there  was  found  some  sort  of  group  recrea- 
tion instituted  and  supported  by  the  employes,  with  or  without  the  co- 
operation of  employers.  In  certain  establishments  this  is  merely  an  informal 
banding  into  social  clubs.  In  others  there  are  carefully  managed  parties 
and  entertainments  for  the  employes  and  their  families.  A  number  of 
organizations  have  bowling  clubs,  baseball  or  basket-ball  teams.  Some 
firms  have  employed  recreation  leaders  who  direct  setting-up  exercises  and 


Health    and     Industry        •  565 

games  at  noon.  Where  this  is  done,  at  the  request  or  with  the  sympathy  of 
the  workers,  excellent  results  have  been  obtained,  but  no  person  wishes  to 
be  coerced  into  play.  The  field  of  recreation  offers  an  excellent  opportunity 
for  the  development  of  employes'  organizations  upon  a  sound  basis.  The 
experience  gained  in  deciding  upon  the  form  and  direction  of  such  activities 
is  excellent  preparation  for  consideration  of  more  serious  issues  which  may 
confront  employes  in  their  industrial  relations. 

The  value  of  group  meetings  is  realized  by  many  establishments  as  a 
result  of  their  liberty  loan  rallies.  Feelings  of  comradeship  and  friendship 
among  employes  are  incentives  to  contentment  in  labor,  and  so  become 
the  modern  equivalent  of  the  spirit  of  craftsmanship.  Group  activities 
which  foster  these  friendly  relations  and  promote  the  feeling  of  solidarity 
among  employes  are  to  be  encouraged. 


Vacations 

Many  firms  have  a  definite  vacation  policy.  Four  factories  in  the  metal 
trades  closed  last  year  for  two  weeks  during  July  or  August.  In  one  instance 
wages  were  paid  for  one  week;  in  another  plant,  during  a  shut-down  of  four 
weeks,  payment  was  made  of  two  weeks'  wages.  Another  firm  offers  one 
week  of  vacation  with  pay  as  a  bonus  to  any  employe  who  has  not  been 
absent  during  the  year,  except  with  a  physician's  certificate  of  illness.  Several 
establishments  reward  old  employes  with  vacations.  One  knitting  mill  has 
adopted  the  policy  of  one  week  of  vacation  with  pay  after  one  year  of  service. 
Another  closes  ten  days  during  the  year  without  pay.  The  garment  fac- 
tories generally  give  one  week  with  pay  after  one  year,  although  in  one 
case  days  of  paid  vacation  are  reckoned  by  periods  of  service  completed. 
Of  the  candy  factories,  two  give  one  week  with  pay  after  one  year,  one  gives 
ten  days  and  another  two  weeks  with  pay.  Other  establishments  recog- 
nize the  desirability  of  vacations  and  permit  leave  of  absence  for  the  purpose. 

Only  two  establishments  were  found  in  which  Saturday  was  not  at  least 
a  half  holiday;  two  garment  factories  have  no  regular  work  on  Saturday. 

Supervision 

There  is  no  uniformity  as  to  methods  of  employment  in  the  various  plants, 
but  in  many  places  the  modern  principle  of  having  all  applicants  pass  through 
one  office  has  been  adopted.  This  office  is  responsible  for  definitely  hiring 
workers  for  all  departments,  and  with  the  advice  of  foremen  usually  decides 
questions  of  adjustment,  discipline  and  discharge. 

For  the  purpose  of  the  Survey  an  establishment  has  been  considered  as 
having  centralized  employment  when  the  authority  to  hire  or  reject  all 
applicants  is  vested  in  one  person  or  office.  (Table  XIV.)  In  eighteen  of 
the  plants  visited  women  were  in  charge  of  hiring  women  employes,  and 
in  some  cases  men  also.  The  plants  of  Cleveland  are  recognizing  more 
and  more  the  value  of  having  women  in  a  supervisory  capacity  where 
women  are  employed. 


566  Hospital  and  Health  Survey 

The  number  and  size  of  plants  having  supervisory  women  appear  in 
Table  XV  which  under  this  term  includes:  employment  managers,  welfare 
directors,  and  those  who  are  in  some  measure  responsible  for  conditions 
affecting  the  work  of  women  in  factories.  Nurses  have  not  been  included 
unless  when  concerned  primarily  with  such  responsibilities  rather  than 
nursing.  Foreladies  have  been  omitted  as  their  sphere  is  usually  limited  to 
direction  of  the  performance  of  manufacturing  operations.  When  there  is 
no  other  woman  in  supervision,  a  forelady  often  successfully  handles  social 
problems  and  acts  as  intermediary  between  the  girls  and  the  management. 
As  the  duties  of  supervisory  women  are  often  not  clearly  defined,  it  has  been 
necessary  to  make  rather  arbitrary  classifications  in  some  instances  for  the 
purpose  of  tabulation.  In  each  of  three  establishments  work  of  this  nature 
is  so  extensive  that  there  is  a  well-organized  department  staffed  by  a  number 
of  women,  each  with  well-recognized  duties.  There  is  clearly  an  important 
place  in  industry  for  the  woman  who  has  by  training  adapted  her  common 
sense  and  personality  to  seeing  fairly  the  problems  of  human  relations  and 
interpreting  them  in  the  everyday  adjustments  of  factory  life. 

The  question  of  health  supervision  for  women  includes  a  special  problem 
discussed  here  rather  than  in  connection  with  general  health  supervision. 
In  almost  every  case  where  plant  nurse,  employment  manager  or  other 
executive  was  asked  about  the  policy  in  regard  to  the  employment  of  preg- 
nant women,  the  reply  was  that  each  case  was  decided  upon  its  individual 
merits.  There  is  need,  however,  of  a  certain  well-defined  standard  of  pro- 
cedure, for  if  left  to  themselves,  many  women  work  longer  than  they  should, 
and  in  their  eagerness  to  conceal  their  condition  may  do  themselves  harm. 
Usually  the  executive  in  charge  of  personnel  is  eager  to  have  any  woman  who 
is  pregnant  leave  work  as  soon  as  or  before  her  condition  becomes  notice- 
able. This  is  often  desirable  where  numbers  of  girls  and  men  are  employed 
in  the  same  departments,  for  comment  cannot  be  avoided  and  is  frequently 
unwholesome.  Several  cases  were  noted  where  special  effort  had  been  made 
to  place  favorably,  pregnant  women  who  were  badly  in  need  of  money  so 
that  they  might  continue  to  work  until  about  the  seventh  or  eighth  month 
under  supervision  of  the  factory  nurse.  It  was  generally  believed  that  ordi- 
narily a  woman  should  not  continue  factory  work  after  the  sixth  month. 
None  of  the  executives  interviewed  wished  women  to  return  to  work  within 
six  months  or  a  year  after  childbirth,  and  except  with  foreign  women  it  is 
seldom  that  any  worker  endeavors  to  return  so  soon.  In  plants  where  foreign 
women  are  employed  without  careful  questioning  or  an  effort  to  learn  of 
home  conditions,  it  may  not  infrequently  happen  that  mothers  of  small 
children  will  be  at  work  when  they  should  be  at  home.  Although  it  is  not 
feasible  to  generalize  for  all  processes  and  industries  regarding  the  limita- 
tions which  should  be  placed  upon  the  employment  of  pregnant  women, 
because  of  variations  in  the  hazard  of  continued  employment,  thoughtful 
consideration  should  be  given  to  the  problems  presented  in  individual  cases, 
and  in  no  event  should  pregnant  women  knowingly  be  permitted  to  work 
within  two  weeks  before,  or  four  weeks  after  childbirth. 


Health     and     Industry  567 

Physical  Conditions  of  Work 

Light,  air,  and  to  some  extent  sanitation  vary  largely  with  the  age  of 
the  plant  equipment.  Many  Cleveland  firms  are  planning  to  build  new 
factories  with  model  installations  and  feel  that  they  should  not  be  judged 
on  present  facilities  meanwhile.  Cleanliness  is  more  difficult  to  maintain 
in  an  old  plant  than,  in  a  new  one,  but  it  can  always  be  achieved  by  dint  of 
special  application  to  the  problem  and  is  important  for  its  moral  effect  as 
well  as  for  physical  comfort.  Toilet  facilities  were  usually  found  to  be  ade- 
quate and  in  compliance  with  the  legal  requirements,  but  in  several  cases 
were  not  entirely  partitioned  off  from  the  main  work-room,  which  is  a  very 
undesirable  arrangement.  Washing  facilities  varied  greatly,  but  on  the 
whole  were  adequate  except  for  a  somewhat  too  limited  supply  of  hot  water. 
Drinking  water  was  usually  provided  by  bubble  fountains,  or  water  coolers. 
Several  common  drinking  cups  were  seen,  as  will  always  be  the  case  when  the 
workers  must  provide  their  own. 

Facilities  for  the  seating  of  workers  were  found  to  be  of  great 
variety,  ranging  from  a  barrel  top  or  a  box  to  the  most  modern  steel  chairs, 
adjustable  for  height  of  seat  and  back.  The  law  requires  that  individual 
establishments  "shall  provide  a  suitable  seat  for  the  use  of  each  female  em- 
ploye and  shall  permit  the  use  of  such  seat  when  such  female  employes 
are  not  necessarily  engaged  in  the  active  duties  for  which  they  are  employed, 
and  when  the  use  thereof  will  not  actually  and  necessarily  interfere  with 
the  proper  discharge  of  the  duties  of  such  employes,  constructed  where 
practicable  with  an  automatic  back  support."  In  practice,  while  chairs  are 
generally  provided  for  at  least  occasional  use,  the  phrase  "interfere  with  the 
proper  discharge  of  their  duties'*  may  be  broadly  interpreted  to  prevent 
the  use  of  chairs  at  any  operation,  and  has  not  resulted  in  the  general  realiza- 
tion that  chairs  can  now  be  designed  for  use  in  connection  with  almost  any 
type  of  work. 

The  law  also  provides  that,  "No  female  under  the  age  of  twenty-one 
years  shall  be  engaged  or  permitted  to  work  at  an  employment  which  com- 
pels her  to  remain  standing  constantly  while  on  duty."  Knitting,  weaving 
and  spinning  are  not  considered  standing  work  because  the  operator  walks 
about  her  machine.  As  it  is  difficult  to  judge  the  ages  of  girls  eighteen  to 
twenty-one,  this  law  is  all  but  impossible  of  enforcement.  A  campaign  for 
education  concerning  better  seating  and  its  use  is  needed  for  both  employers 
and  employes.  It  is  true  that  employes  often  will  not  choose  to  sit  at  their 
work,  and  old  employes  frequently  object  to  new  types  of  chairs  with  backs. 
Operatives  can  usually  be  won  over  to  acceptance  of  an  appliance  which 
is  really  to  their  advantage  by  a  patient  and  persistent  demonstration  of 
its  merits. 

Lockers  are  another  institution  which  often  cause  the  employer  to  weary 
of  well-doing,  for  keys  are  lost  and  many  workers  will  not  use  locks  when  they 
are  furnished.  Twenty-five  establishments  reported  that  they  had  lockers, 
usually  of  steel,  one  for  each  person.  Other  firms  use  racks  in  a  dressing- 
room.  Only  two  cases  were  found  where  clothing  was  hanging  in  the  work- 
room. 


568  Hospital  and  Health  Survey 

Couches  were  provided  for  women  employes  in  thirty-two  establishments. 
This  might  mean  a  single  couch  in  a  room  crowded  with  wraps,  or  a  com- 
fortable bed  in  a  silence-room  or  dispensary.  Many  plants  have,  in  addi- 
tion to  a  dispensary  bed,  a  room  with  several  couches  to  be  used  for  rest  when 
needed.  The  plant  which  has  no  cot  available  for  an  emergency  is  not  properly 
equipped  to  care  for  women  employes. 


MERCANTILE  ESTABLISHMENTS 

In  the  seven  mercantile  establishments  visited,  6,730  women  are  em- 
ployed. 

Department  stores  have  uniform  closing  hours,  giving  them  forty-eight 
hours  per  week,  except  a  few  that  remain  open  an  extra  half-hour  on  Satur- 
day. During  July  and  August  a  number  of  the  stores  are  closed  all  day 
either  Saturday  or  Monday.  The  vacation  policy  varies  slightly,  but  all 
stores  grant  a  week  with  pay  after  a  certain  period  of  service,  which  may  be 
three,  six,  nine,  or  twelve  months,  and  usually  two  weeks  with  pay  is  given 
after  a  longer  service. 

Department  stores  have  developed  a  special  service  for  employes  in 
their  educational  departments.  It  is  helpful  to  a  new  employe  to  have 
the  necessary  information  as  to  store  policy  and  department  relations  pre- 
sented in  definite  fashion.  Through  careful  observation,  the  ability  of  the 
individual  may  be  directed  into  the  most  fruitful  channels.  There  is  in 
many  mercantile  establishments  opportunity  for  advancement,  and  effort 
is  encouraged  by  the  knowledge  that  many  buyers  and  executives  have 
worked  their  way  up  through  the  store.  Classes  in  salesmanship  give  added 
zest  to  selling  as  well  as  increased  earning  in  commissions. 

Efficient  employment  is  an  important  preliminary  to  the  work  of  the 
educational  department,  and  the  health  of  employes  as  well  should  be 
carefully  considered.  Several  of  the  stores  are  now  giving  attention  to  the 
development  of  adequate  health  departments. 

Starting  rates  vary  with  the  age  and  ability  of  the  worker.  For  the  stock, 
cashier  and  inspection  departments,  two  stores  have  a  minimum  of  $10  per 
week,  while  others  do  not  give  less  than  $12  or  $13.  For  selling  on  a  com- 
mission basis,  the  usual  minimum  is  $15  per  week. 

Several  stores  have  women  elevator  operators  who  are  said  to  be  more 
satisfactory  than  the  men  who  are  obtainable.  Where  doors  are  arranged 
to  open  easily,  little  physical  effort  is  required,  but  adequate  opportunity 
for  rest  should  be  provided  to  relieve  the  nervous  strain  of  constant  atten- 
tion to  an  important  duty,  while  at  the  same  time  treating  passengers  with 
courtesy  and  answering  questions.  Rest  periods  are  provided  in  practically 
all  establishments  by  the  use  of  a  relief  operator.  Except  in  one-way  ele- 
vators standing  is  usually  constant  in  busy  hours,  but  suitable  seats  should 
be  available  for  use  upon  occasion. 


Health     and     Industry  569 

Women  also  operate  elevators  in  several  hotels  and  public  buildings. 
This  is  another  kind  of  work  on  which  colored  women  are  frequently  employed. 
$14  per  week  is  the  lowest  of  the  wage  rates  reported  for  elevator  operators. 

PUBLIC-SERVICE  ORGANIZATIONS 

Laundries 

It  is  unfortunate  that  conditions  for  workers  in  laundries  at  present 
seem  to  be  in  some  ways  poorer  than  in  the  past.  The  services  of  a  woman 
supervisor  have  been  given  up  in  one  place,  use  of  lockers,  cafeteria  and 
recreation  in  another.  Labor  cost  is  fifty  per  cent  of  the  cost  of  laundering, 
and  as  the  public  resents  increased  prices,  it  is  difficult  for  laundries  to  raise 
their  wage  rates  to  a  point  of  competition  with  factories.  Consequently 
the  scarcity  of  female  labor  is  severely  felt  in  laundries.  Some  plants  were 
so  short-handed  that  managers  and  executives  had  to  take  the  places  of 
absent  workers.  Porter  service  was  most  inadequate  and  often  the  laundry 
housekeeping  was  poorly  done. 

The  attitude  of  laundry  men  toward  their  workers  varied  greatly.  Some 
were  indifferent  to  the  objectionable  features  of  the  work.  Others  maintained 
that  standing  was  not  harmful,  that  high  humidity  was  beneficial,  and  that 
marking  soiled  clothes  was  a  particularly  healthful  occupation.  In  one 
laundry  there  was  an  effort  made  to  seat  all  employes  so  far  as  possible.  New 
machines,  often  designed  so  that  the  worker  could  be  seated,  were  being- 
installed  beside  old  ones,  showing  the  advances  in  this  direction  and  suggest- 
ing further  improvements  that  should  follow  if  the  comfort  of  workers  is 
to  receive  the  same  consideration  in  laundries  that  it  does  in  most  factories. 
Ventilating  devices  were  generally  used,  although  often  they  were  ineffec- 
tive. It  would  seem  that  much  of  the  steam  could  be  kept  from  the  general 
work-room  by  partitioning  off  the  section  used  for  washing,  and  mangles 
could  also  be  installed  in  separate  rooms,  although  there  is  no  excuse  for  a 
noticeable  escape  of  steam  from  mangles  when  excellent  exhausts  are,  avail- 
able. 

The  nature  of  laundry  work  makes  it  particularly  desirable  that  em- 
ployes' wraps  should  not  be  left  in  the  work-room,  that  separate  lunch- 
rooms should  be  provided,  that  toilet  and  washing  facilities  should  be  ade- 
quate, but  this  was  not  always  the  case. 

It  is  interesting  that  even  the  less  progressive  laundry  men  speak  of  the 
laundry  as  a  type  of  public  service,  and  feel  a  responsibility  to  serve  their 
customers  faithfully,  especially  when  there  is  much  general  sickness  as  was 
the  case  this  winter.  One  manager  considered  that  the  importance  of  getting 
the  work  done  outweighed  the  importance  of  good  working  conditions  for 
laundry  workers  so  long  as  there  was  no  violation  of  the  law.  Often  the 
law's  minimum  is  considered  the  only  reasonable  maximum. 

The  scarcity  of  labor  has  resulted  in  the  use  of  colored  girls  in  three  of 
the  commercial  laundries  visited,  and  three  of  the  hotel  laundries.  Separate 
coat  rooms,  toilets  and  eating  facilities  were  usually  provided.     The  colored 


570  Hospital  and  Health  Survey 

workers  were  generally  considered  less  efficient,  and  much  slower  to  learn 
the  work — which  was  given  as  the  reason  for  their  lower  wage.  Colored 
girls  started  at  $10  where  white  beginners  received  $13.  In  two  laundries 
white  girls  received  $14  for  a  starting  rate,  in  another,  $12.  The  average 
for  laundry  workers  seemed  to  be  about  $17. 

The  variation  of  busy  and  slack  days  has  been  largely  eliminated  from 
laundries  by  daily  collections  of  clothes  from  patrons.  There  is  said  to  be 
no  overtime  for  women.  Two  plants  work  fifty  hours,  one  forty-nine,  and 
two.  forty-seven  hours. 


Hotels 

In  spite  of  the  inclusion  of  the  word  "hotel"  in  the  Industrial  Com- 
mission's definition  of  "shops  and  factories,"  there  seems  to  be  doubt  as 
to  whether  hotels  do  come  under  the  supervision  of  the  Industrial  Com- 
mission, especially  since  enforcement  of  "Laws  Providing  for  Inspection  and 
Licensing  of  Hotels  and  Restaurants"  has  recently  been  entrusted  to  the 
department  of  the  State  Fire  Marshal,  although  with  no  mention  of  kinds 
of  work  or  hours  for  employes.  The  hotel  department  heads  were  of  the 
impression  that  some  restrictions  existed  but  were  vague  as  to  their  nature. 

Hotel  and  restaurant  workers  are  said  to  be  confirmed  floaters.  Some  of 
the  women  live  in  hotel  dormitories,  with  board  in  addition  to  their  monthly 
wage;  some  live  outside,  receiving  two  meals  daily  besides  a  weekly  wage;, 
and  others  live  outside  and  carry  their  own  meals.  Earnings  depend  in 
part  unon  tips  and  cannot  be  accurately  estimated.  They  are  often  larger 
potentially  than  in  reality,  especially  for  chamber-maids.  The  stated 
sum  paid  for  similar  work  in  different  places  varied,  and  in  general  there 
seemed  to  be  little  opportunity  for  increases  based  on  efficiency  or  length 
of  service,  a'though  one  hotel  has  groiro  insurance  and  a  bonus  as  incentives 
to  continued  employment. 

The  decentralization  of  responsibility  in  hotels  rather  surprises  the 
inquirer  who  must  go  from  department  to  department  to  learn  of  the  various 
types  of  workers  and  the  conditions  of  their  employment.  The  hotel  manager 
has  two  problems — serving  the  public  and  maintaining  a  staff  of  employes 
to  render  that  service.  As  catering  to  the  public  is  the  fundamental  pur- 
pose of  a  hotel,  it  receives  most  of  the  manager's  attention,  and  the  demands 
of  the  public  are  so  varied  that  a  great  amount  of  detail  is  involved.  The 
problems  incident  to  maintaining  a  staff  of  employes  are  left  to  those  in 
charge  of  the  several  departments,  which  are  conducted  quite  independently 
of  each  other.  The  effectiveness  of  such  an  arrangement  depends,  of  course, 
noon  the  efficiency  of  department  heads.  As  stewards  and  hotel  house- 
keepers  are  somewhat  temperamental,  and  invariably  complain  of  the  un- 
reasonableness of  their  employes  who  stay  only  a  short  time,  it  seems  pos- 
sible that  the  present  method  of  hiring  and  dealing  with  employes  in  hotels 
might  be  replaced  to  advantage  by  an  organized  central  employment  service 
similar  to  that  used  in  industries,  in  many  of  which  the  requirements  for 
different  types  of  employes  are  as  varied  as  in  hotels. 


Health     a  n  d     Indus  t  r  v  57 1 


Restaurants 

Waitresses  are  one  of  the  few  groups  of  women  strongly  unionized  in 
Cleveland.  Their  wage  scale  of  $12  to  $18  per  week  in  addition  to  meals 
and  tips,  prevails  in  the  city.  They  work  eight  hours  for  six  days  per  week, 
but  often  the  day  is  broken  in  two  parts  with  the  afternoon  hours  free.  These 
cannot  be  well  utilized,  and  the  union  is  about  to  campaign  for  all  straight 
watches  of  eight  continuous  hours.  By  using  the  shift  system  some  managers 
have  practically  all  of  their  waitresses  working  continuous  hours. 

While  restaurants  and  cafeterias  in  many  cases  seem  slow  to  provide 
facilities  for  the  comfort  of  employes,  some  progressive  managers  have 
taken  these  matters  into  consideration,  and  are  also  planning  centralized 
employment,  employes'  organizations,  and  medical  service  for  workers. 


PUBLIC  UTILITIES 

The  difficulties  of  poor  telephone  service  are  well  known  to  the  public, 
but  the  reasons  back  of  it  require  special  study.  Operators  are  scarce, 
special  urging  is  often  needed  to  induce  girls  to  enter  this  field,  and  many 
of  them  stay  for  but  a  short  time.  The  low  wages  paid  have  been  one  very 
evident  reason.  Changes  have  recently  been  effected  in  Cleveland,  but 
comparison  with  most  industrial  work  is  still  unfavorable.  The  nervous 
tension  under  which  the  work  must  be  performed  is  trying  to  many  tem- 
peraments. This  has  been  recognized  to  a  degree  by  the  provision  of  a 
fifteen-minute  rest  period  in  each  three  and  one-half  or  four  hour  period  of 
duty.  Whether  this  is  sufficient  for  relaxation  from  such  work  is  something 
that  should  be  carefully  studied  and  every  effort  made  to  preserve  the  routine 
so  that  no  matter  what  the  pressure  of  traffic  may  be,  the  rests  need  never 
be  omitted.  Rather  than  deny  the  nervous  strain  of  telephone  work,  it 
would  seem  that  companies  might  well  devote  themselves  to  special  study 
of  methods  for  lessening  the  strain  on  operators.  The  public  should  be 
better  informed  as  to  the  conditions  under  which  operators  work,  in  order  that 
they  may  cooperate  with  telephone  companies  to  improve  service  by  properly 
signalling  operators,  carefully  giving  numbers,  and  displaying  a  reasonable 
patience. , 

The  telegraph  companies  employ  several  hundred  girls  as  telegraph 
operators.  Others  are  in  the  telephone  department.  All  of  this  work 
requires  a  keen  mind  and  a  combination  of  speed  and  exactness  in  opera- 
tion that  would  seem  to  deserve  better  pay  than  is  generally  given. 

GENERAL  DISCUSSION 

Night  Work 

The  difficulty  of  securing  an  adequate  supply  of  female  labor  has  already 
been  discussed.  One  of  the  results  of  this  labor  scarcity  has  been  to  cause 
several  manufacturers,  under  pressure  of  unfilled  orders,  to  see  in  night 
work  the  simplest   solution   of  their  problem.     There  are  women  eager  to 


5  72  Hospital  and  Health  Survey 

work  at  night,  and  many  firms  report  that  women  are  turned  away  from 
the  night  shift  though  they  cannot  be  secured  for  work  by  day.  These  women 
have  families  of  small  children  for  which  they  must  care  during  the  day. 
At  night  their  husbands  come  home  and  assume  the  responsibility  of  family 
care  so  that  the  mothers  may  go  to  the  factory.  Here  they  may  work  from 
five  o'clock  to  ten,  or  more  likely  from  three  to  eleven,  five  to  twelve,  or 
six  to  two,  and  in  one  plant  from  six  to  half  past  four  in  the  morning. 

It  is  hard  to  believe  that  after  a  day's  housework  and  the  care  of  small 
children  a  woman  is  in  any  condition  to  be  a  good  factory  operative,  but 
many  employers  seem  to  feel  that  night  work  is  very  satisfactory.  As  most 
of  the  night  shifts  have  begun  in  the  past  six  months,  the  effect  of  a  woman's 
holding  two  jobs  has  not  become  apparent  in  the  quality  of  her  work.  The 
result  will  be  sooner  evident  in  her  home,  for  even  a  sturdy  woman  of  the 
European  peasant  type  cannot  long  stand  such  double  duty  without  impair- 
ing her  physical  condition,  the  first  effect  of  which  will  be  upon  her  children. 
A  hard-working  mother  with  insufficient  sleep  is  apt  to  be  irritable,  and 
even  if  she  is  conscientious  enough  to  feed  and  clothe  her  children  properly, 
their  tempers  are  apt  to  reflect  her  own.  Of  real  home  life  there  can  be  none 
when  father  and  mother  scarcely  see  each  other,  and  the  inculcation  of 
American  ideals  under  such  circumstances  is  a  barren  hope. 

The  Survey  has  a  record  of  980  women  who  were  working  on  night  shifts 
in  fifteen  Cleveland  factories  on  April  loth.  Of  these  652  were  employed 
in  the  textile  and  knitting  mills  and  328  in  the  metal  trades. 

Aside  from  the  effect  upon  home  life,  and  the  street  dangers  at  night,  the 
night  work  in  the  factory  itself  is  not  so  pleasant  as  it  is  by  day.  Factory 
illumination  generally  is  none  too  good.  'At  night  with  only  artificial  light- 
ing it  is  usually  worse.  Other  parts  of  the  building  are  dark,  and  there  is 
a  sense  of  the  uncanny  about  being  at  work  when  naturally  one  should  be 
asleep.  In  factories  where  there  are  cafeterias,  and  dispensaries  for  the  use 
of  the  day  force,  these  facilities  are  seldom  available  at  night.  Often  there 
is  no  definite  pause  for  eating,  even  in  a  seven  or  eight-hour  shift.  There  is 
almost  never  the  same  supervision  at  night  that  there  is  during  the  day, 
and  where  both  men  and  women  are  employed  there  is  even  more  reason 
for  it. 

Night  work  is  possibly  but  a  temporary  measure.  The  experience  of 
England  during  the  war  and,  before  that,  the  feeling  that  led  six  European 
countries  to  agree  to  prohibit  night  work  for  women,  should  make  our  people 
consider  the  institution  carefully  before  we  sanction  its  use  even  in  an  emer- 
gency threatening  the  life  of  the  nation — and  such  an  emergency  does  not 
now  exist.  So  long  as  there  is  no  hindrance  to  the  establishment  of  night 
shifts  for  women,  there  will  be  temptation  to  meet  orders  by  this  means 
rather  than  by  improved  management,  routing  and  planning  of  work.  It 
would  be  well  for  Ohio  to  record  on  its  statute  books  its  opposition  to  the 
employment  of  women  at  night.  At  present  there  is  not  even  an  avenue  for 
learning  the  full  extent  of  night  work,  as  there  is  no  requirement  for  reporting 
night  shifts  to  the  Industrial  Commission  and  no  method  for  its  control  except 
through  chance  visits  of  state  inspectors. 


Health     and     Industry  573 

The  telephone  and  telegraph  companies  employ  a  few  women  at  night, 
and  there  is  an  occasional  small  restaurant  with  night  waitresses.  Girl 
ushers  are  used  in  several  of  the  theatres  and  moving-picture  houses,  but 
in  small  numbers.  Aside  from  factories  the  largest  number  of  women  who 
work  at  night  are  those  who  clean  office  buildings.  They  usually  work 
eight  hours,  and  it  may  be  at  any  time  of  the  night  or  early  morning,  although 
the  shift  from  five  to  twelve  o'clock  is  most  popular,  leaving,  as  it  does,  a 
little  of  the  night  for  sleeping.  The  women  are  usually  hired  by  the  fore- 
lady  in  charge,  and  are  in  large  proportion  foreign.  They  frequently  bring 
neighbors  to  work  with  them  to  avoid  the  journey  home  alone.  These 
women  speak  their  native  languages,  and  enjoy  the  informality  of  the  work, 
though  there  is  no  question  about  the  fatigue  in  connection  with  scrubbing 
and  carrying  heavy  pails  of  water,  frequently  with  no  elevator  service.  In 
April  a  night  cleaning  woman  was  killed  while  on  the  way  to  her  home  in  a 
Cleveland  suburb  and  robbed  of  her  pay. 


Home  Work    . 

A  means  of  adding  to  the  day's  output  utilized  by  a  number  of  factories 
is  homework.  Parts  of  sweaters  are  frequently  joined  by  a  stitch  done  by* 
hand,  and  use  of  factory  space  for  this  work  is  avoided  in  many  cases  by 
sending  the  work  to  the  homes  of  women  who  have  spent  a  few  days  in  the 
factory  learning  the  work.  It  is  estimated  that  at  least  225  women  work 
on  sweaters  and  other  knit  goods  in  their  homes.  Except  for  the  delivery 
and  collection  of  material  by  some  of  the  firms,  there  is  no  overhead  expense 
in  connection  with  home  work,  so  that  it  is  difficult  to  understand  why  rates 
for  this  work  should  be  so  low. 

A  number  of  factories  have  established  small  branch  factories,  occasion- 
ally located  in  connection  with  a  dwelling,  but  under  the  law  considered  work- 
shops only  when  they  are  the  assembly  place  for  workers  other  than  those 
living  in  such  a  dwelling.  Between  this  type  of  workshop  and  the  service 
rendered  by  women  sewing  by  hand  in  their  own  homes,  there  is  another 
type  of  industrial  service  performed  by  the  women  in  whose  homes  a  com- 
pany has  installed  a  power  machine.  While  the  Industrial  Commission 
inspects  the  main  factories  and  the  smaller  branch  shops,  it  is  not  practicable 
for  inspectors  to  maintain  adequate  supervision  of  the  conditions  under 
which  work  is  performed  in  the  homes  of  individual  workers. 

There  is  a  variety  of  home  work.  An  occasional  garment  factory  sends 
out  cuffs  to  be  turned.  The  carding  of  snaps  and  fasteners  employs  about 
one  hundred  women.  This  work  is  done  entirely  in  the  homes,  and  the 
workers  must  carry  supplies  back  and  forth  to  the  factory.  The  earnings 
seem  very  little  for  the  time  required,  but  the  work  is  light  and  many  women 
have  probably  been  able  to  earn  in  this  way  who  would  otherwise  not  have 
been  able  to  do  so.  Stringing  of  sales  tags  is  another  type  of  home  work 
done  mostly  by  children,  some  of  whom  object  to  the  low  rates  of  pay.  In 
season  there  is  also  the  home  trimming  of  tailored  hats,  which  are  delivered 
by  the  case.    A  few  women  work  on  brushes  at  home. 


.574  Hospital  and  Health  Survey 

While  the  advantages  of  home  work  for  crippled  or  convalescent  patients 
has  given  interest  to  its  possibilities  in  special  cases,  the  general  increase  of 
home  work,  due  to  current  high  prices  on  the  one  hand  and  the  demands 
of  employers  for  labor  on  the  other,  must  be  carefully  watched.  The  repeti- 
tion of  such  abuses  of  home  work  as  were  revealed  by  studies  of  conditions 
in  New  York  should  be  avoided. 

.  Not  only  in  this  country  but  abroad  has  it  been  observed  that  more 
unfavorable  conditions  for  the  children  are  created  where  their  mothers  do 
industrial  work  in  their  homes,  than  result  from  other  forms  of  work  under- 
taken by  married  women.  Carmagnano,  in  Pediatria  (March,  19*20,  XXVIII, 
Xo.  5),  believes  that  we  should  go  so  far  as  to  provide  legal  measures  to 
protect  prospective  and  nursing  mothers  who  are  engaged  in  wage-earning 
or  piece-work  at  home,  as  we  protect  them  in  factory  work. 


Day  Xurseries 

In  almost  every  establishment  visited,  more  married  women  were  em- 
ployed than  ever  before.  Many  of  these  were  young  women  with  few  home 
'responsibilities,  for  it  was  frequently  said  that  in  these  days  working  girls 
return  to  the  factory  or  store  a  few  days  after  they  are  married.  Many, 
however,  are  women  with  families  who  find  even  the  fairly  good  wages  of 
their  husbands  insufficient  for  the  family  needs,  or  those  who  wish  to  pro- 
vide for  the  future  by  laying  something  aside  now  that  wages  are  high,  or 
others  who  are  helping  to  pay  for  a  home  or  sending  money  to  suffering 
relatives  in  Europe. 

Many  complaints  come  from  the  schools  that  children  of  school  age  are 
kept  at  home  to  care  for  the  younger  members  of  the  family,  or  in  other 
cases  that  mothers  are  either  leaving  the  children  to  run  the  streets  or  lock- 
ing them  in  their  houses  while  the  mothers  are  at  work.  .More  than  one 
child  left  in  this  way  has  been  burned  to  death. 

Whether  mothers  of  small  children  should  be  permitted  to  work  is  a 
difficult  social  problem.  They  cannot  be  legislated  into  their  homes,  nor 
should  they  be  encouraged  to  evade  responsibilities  by  day-nursery  facilities. 
On  the  other  hand  the  children  cannot  be  permitted  to  be  neglected.  Day 
nurseries  have  provided  care  for  some  children  whose  mothers  are  obliged 
to  work.  337  such  children  were  cared  for  by  the  Day  Xursery  and  Free 
Kindergarten  Association  last  year.  The  day  nursery,  however,  is  an  expen- 
sive institution,  and  we  have  little  information  from  which  to  judge  its  net 
social  worth. 

If  working  women  were  to  be  charged  one  dollar  per  day  per  child,  which 
is  the  approximate  cost  of  nursery  care,  probably  few  women  would  use 
day  nurseries.  Should  the  community  then  contribute  to  the  support  of  the 
families  of  those  mothers  by  supplying  nursery  care  for  a  slight  fee,  encourag- 
ing the  mothers  to  work  outside  their  homes  and  leave  their  children  for 
the  group  care  of  the  nursery?     If  such' is  to  be  the  case  the  community 


Health     and     Industry  575 

must  insist  that  this  care  be  of  the  best  and  that  preventive  health  measures 
for  the  young  child  be  used  to  ward  off  later  illnesses  and  defects  so  far  as 
possible,  in  order  that  the  eventual  economic  cost  to  the  community  may 
not  be  too  high. 

Mothers  are  working  at  the  present  time.  The  care  that  should  be  given 
to  their  children  is  a  community  health  problem  with  economic  and  social 
aspects  so  important  that  each  community  should  give  careful  study  to 
its  own  situation. 

Mothers'  Pensions 

The  provision  of  mothers'  pensions  has  been  a  partial  approach  to  the 
same  problem,  but  is  applicable  only  in  cases  of  widows  who  are  mentally 
and  morally  sound  and  whose  legal  residence  is  established.  Even  where 
mothers'  pensions  can  be  granted,  they  are  most  inadequate.  $15  per  month 
for  the  first  child  and  $7  for  each  additional  child,  is  the  maximum  per- 
mitted. This  maximum  is  always  granted  in  Cuyahoga  County,  but  is 
so  inadequate  that  in  numbers  of  cases  the  pension  must  be  supplemented 
by  the  Associated  Charities. 

In  some  counties,  however,  no  pensions  are  given,  and  in  others  the 
amount  is  very  small,  so  that  great  effort  will  be  required  to  arouse  sufficient 
public  opinion  through  the  state  to  secure  legislative  increase  of  the  maxi- 
mum. 

The  court  takes  the  stand  that  no  mother  may  receive  a  pension  if  she 
works  more  than  three  days  a  week,  which  means  that  a  widow  with  four 
children  is  faced  with  the  alternatives  of  receiving  a  pension  of  $36  per 
month  or  of  earning  a  living  for  the  family. 


RECOMMENDA  TIONS 

It  is  the  recommendation  of  the  Survey — 

That  industrial  and  other  establishments  bring  to  the  attention  of 
employes  the  health  value  of  suitable  working  clothing,  with  special  regard 
for  the  advantages  of  proper  footwear  for  women  who  are  much  upon  their 
feet,  and  for  the  safety  of  women  in  machine  trades. 

That  in  establishments  where  there  is  routine  physical  examination  of 
men,  women  employes  be  admitted  to  an  examination  of  similar  nature. 

That  uncertainty  of  the  adequacy  of  piece-work  earnings  be  obviated 
by  a  guaranteed  minimum  wage-rate  when  practicable. 

That  the  industries  of  Cleveland  devote  special  consideration  to  the 
elimination  of  hazards  of  accident  and  illness  where  women  are  employed. 

That  various  industries  endeavor  to  eliminate  seasonal  variations  in 
employment  through  regularization  of  work. 


576  Hospital  and  Health  Survey 

That  special  effort  be  made  to  interest  both  employers  and  employes 
in  the  use  of  seating  suitable  for  different  operations,  and  that  where  possible 
chairs  be  adjustable  for  height  of  seat  and  back. 

That  every  establishment  employing  women  provide  one  or  more 
couches  for  the  use  of  such  employes. 

That  the  municipal  department  of  health  maintain  careful  supervision  of 
laundries  with  special  reference  to  the  comfort  and  health  of  employes. 

That  the  public  be  more  adequately  informed  regarding  the  technical 
difficulties  incident  to  maintenance  of  a  telephone  service,  to  the  end  that 
its  cooperation  be  secured  in  a  reduction  of  the  hazard  of  nerve  strain  for 
telephone  operators,  and  a  consequent  improvement  of  a  service  which  at 
present  is  essentially  dependent  upon  the  high  efficiency  of  a  human  factor. 

That  night  work  of  women  be  prohibited  by  law,  except  in  essential 
public  utilities. 

That  greater  publicity  be  given  to  provisions  of  the  laws  of  the  State 
of  Ohio  governing  conditions  of  employment. 

That  the  number  of  women  inspectors  of  the  Industrial  Commission 
assigned  to  the  Cleveland  district  be  increased  in  order  that  the  conditions 
attending  the  employment  of  women  and  children  in  individual  establish- 
ments may  be  observed  more  frequently  than  at  the  yearly  intervals  at 
present  prevailing. 


INTEREST  OF  THE  COMMUNITY 

The  hope  of  solution  of  the  various  problems  in  connection  with  the 
employment  of  women  lies  in  the  interest  of  the  community.  The  Young 
Women's  Christian  Association  has,  through  its  Industrial  Extension  De- 
partment and  more  recently  through  the  Industrial  Women's  Club,  taken 
an  active  part  in  recreation  for  working  girls,  and  has  also  attempted,  by 
educational  means,  to  prepare  these  girls  to  think  out  their  problems  for 
themselves. 

The  Vacation  Savings  Club  has  been  effective  in  the  encouragement  of 
thrift  among  working  people,  especially  women. 

The  Girls'  City  Club  has  been  recently  established  by  the  League  of 
Women  Workers,  with  the  aid  of  secretaries  of  the  Vacation  Savings  Club, 
and  affords  a  downtown  social  club  for  girls,  with  a  variety  of  recreation 
and  classes. 

The  local  branch  of  the  Consumers'  League  has  taken  an  active  interest 
in  the  various  aspects  of  the  work  of  women,  and  is  cooperating  with  other 
agencies  in  an  effort  to  learn  actual  conditions  of  work  in  relation  to  present 
and  proposed  legislation,  and  to  learn  the  opinions  of  thinking  working 
women  concerning  their  own  problems. 


Health     and     Industry  577 

The  State-City  Free  Employment  Bureau  is  interested  in  the  work  of 
women  from  the  practical  point  of  view  of  placement.  The  worth  of  such  a 
central  agency  for  employment  has  been  demonstrated  in  many  places,  and 
its  usefulness  grows  as  it  is  used. 

Where  working  women  play  so  important  a  part  in  the  industrial  life  of 
a  city  as  they  do  in  Cleveland,  there  is  reason  to  hope  and  believe  that  the 
people  of  the  city  will  consider  and  protect  their  interests. 


When  a  Feller  Needs  a  Friend 


-      By  BRJGGS 


York   TrtbTnio   It.- 


DECLARATION  OF  DEPENDENCE 


mU^m  That  childhood  15 

endowed  with  certain  inherent  and. 

inalienable  rights  among  which  are  jgjjBgii 

freedom*  from  toil  for  daily  bread,  Jlslll^BB 

the  right  to  play  and  to  dream  - 

the  right  to  Hie  normal  5leep  or 

the  night' season;  the  right  to 

an  education  that  we  rpay  have 

equality  of  opportunity  for  develop 

ing  oil  that  there'  15  in  us  of 

mmd  and.  h^art"        */<•  tip/way 


Courtesy  Neu    Yorlf  Tribune  and  The  Cleveland  Pr 


578 


Health     a  x  d     Industry  579 

Children  ana  Industry 

By  Florence  V.  Ball 

INTRODUCTORY 

A  STUDY  of  children  and  industry  is  included  in  the  report  of  the  Hos- 
pital and  Health  Survey  because  the  health  of  the  large  portion  of  the 
city's  population  who  are  going  to  be  its  industrial  workers  depends  largely 
upon  what  provisions  are  made  for  their  welfare  during  the  period  when 
they  are  15-18  years  old.  The  years  from  15-18  are  the  adolescent  years, 
and  children  of  this  age  face  especial  health  problems  which  must  have  care- 
ful attention.  Out  of  the  children  who  go  to  work  are  developed  the  future 
industrial  workers  and  citizens  of  the  city.  If  only  a  few  of  the  children  in 
the  community  were  going  to  work  it  might  not  be  important  from  a  health 
standpoint  to  consider  their  interests  so  carefully.  But  at  17  years  of  age 
75%  of  the  children  of  Cleveland  are  already  at  work,  and  many  of  them  have 
been  at  work  for  two  or  three  years  previously.  They  are  no  longer  under 
the  direct  care  of  school  medical  authorities.  Neither  are  their  especial 
needs  studied  and  provided  for  in  industrial  medical  service.  Unless  special 
supervision  is  provided  for  children  of  these  years,  their  passage  into  industry 
is  unguarded  and  unguided,  and  irreparable  damage  may  be  done  to  their 
mental  and  physical  well-being,  which  will  have  serious  results  both  in  their 
own  future  and  in  that  of  the  community. 

Nor  is  the  sound  health  of  this  group  of  children  assured  by  considera- 
tion of  their  physical  wants  alone.  Their  problem  is  a  psychological  as  well 
as  a  physiological  one.  The  degree  of  adjustment  between  children  and 
their  first  jobs,  the  success  of  their  transition  from  school  into  industry, 
the  amount  of  preparation  which  they  have  had  for  industrial  life,  are  all 
factors  of  great  power  in  determining  their  development  from  childhood  into 
sound  maturity. 

A  study  of  children  and  industry  from  a  health  standpoint  involves  three 
general  considerations:  first,  measures  taken  to  protect  the  health  of  chil- 
dren upon  entrance  into  industry,  by  the  adoption  of  requisite  health  stand- 
ards; second,  regulation  of  their  industrial  careers  until  they  reach  matur- 
ity, which  means  a  study  of  legal  restrictions  of  children's  work  as  well  as  a 
study  of  present  conditions  under  which  they  work;  and,  third,  the  more 
indirect  but  no  less  important  relation  between  educational  preparation, 
adjustment  with  the  job  and  sound  health. 

Under  what  circumstances  are  children  going  to  work?  What  measures 
have  been  taken  to  develop  their  bodies  and  make  them  physicially  fit  to 
enter  industrial  life?  What  kind  of  work  are  children  doing  and  what  kind 
of  a  chance  does  it  offer  them  for  future  industrial  competency?  What  hap- 
pens to  children  at  work  who  are  not  normal,  mentally  or  physically?  What 
in  education  has  prepared  children  for  the  shift  from  school  to  eight  hours  of 
labor  daily,  at  work  quite  different  from  the  sort  of  activity  which  has  char- 


580  Hospital  and  Health  Survey 

acterized  their  school  life?  What  is  going  to  be  the  effect  of  such  a  radical 
change  on  growing  boys  and  girls,  whose  physical  and  mental  instability  at 
this  time  is  marked? 

Childhood  naturally  falls  into  several  distinct  periods,  the  prenatal  period, 
infancy,  the  pre-school  period,  the  school  period  and  the  adolescent  period. 
Each  of  these  periods  is  important  in  the  welfare  of  children.  To  those 
interested  in  one  particular  stage  of  a  child's  development,  that  one  may 
seem  of  paramount  importance.  Probably  not  until  all  periods  are  equally 
emphasized  will  children  have  a  full  chance  for  development.  However,  the 
successive  needs  of  childhood  may  be  viewed,  no  one  will  deny  the  need  for 
careful  instruction  and  guidance  during  the  adolescent  years.  All  of  the 
care  which  has  been  given  to  children's  health  in  earlier  years  will  prove  to 
have  been  futile  if  they  are  allowed  to  go  free  from  guidance  and  protection 
in  these  later  years  before  they  are  competent  to  take  care  of  themselves. 
The  physical  and  moral  difficulties  which  approaching  maturity  thrusts  on 
them,  require  for  children  assistance  and  advice  and  often  medical  care,  in 
order  to  safeguard  their  health,  as  well  as  to  complete  the  training  and  prep- 
aration which  have  been  the  work  of  society  for  the  14  or  15  preceding  years. 

These  are  the  years  of  transition  from  supervised  childhood  to  indepen- 
dent maturity.  Opinion  is  divided  as  to  the  advisability  of  allowing  chil- 
dren to  go  to  work  during  this  period.  One  point  of  view  sees  always  the 
child  in  the  developing  boy  and  girl  and  desires  for  the  child  the  maximum 
of  care  and  protection.  This  protective  care  can  go  too  far  and,  in  extreme, 
smothers  the  springs  of  initiative  and  self-reliance  needed  in  the  man.  The 
other  point  of  view,  more  hard-headed,  believes  that  participation  in  the 
work  of  the  world  cannot  begin  too  soon  for  sturdy  development.  In  its 
interest  in  independent  character  it  tends  to  lose  sight  of  the  fact  that  too 
early  work  stunts  a  child's  development  and  that  a  sound  mind  should 
be  combined  with  a  healthy  body  in  order  to  realize  its  greatest  powers. 
Another  point  of  view,  the  commercial  one,  of  the  dollar  value  of  child  labor, 
should  not  be  seriously  considered.  Obviously  the  industry  of  this  country 
does  not  have  to  depend  on  the  work  of  children  for  its  income,  although  it 
is  chiefly  to  combat  the  commercially-minded  that  it  is  necessary  to  make 
such  strictly  defined  child-labor  laws.  Otherwise,  it  would  be  possible  to 
make  laws  elastic,  in  order  to  meet  more  easily  the  individual  needs  of  chil- 
dren. 

It  is  our  belief  that  the  efforts  made  on  behalf  of  children  of  adolescent 
years,  regarding  their  passage  from  school  to  work,  should  be  directed 
towards  individual  adjustments.  In  concern  for  the  child,  the  man  in  the 
developing  boy  should  not  be  overlooked,  neither  should  the  child  be 
allowed  to  enter  the  adult's  world  of  work  too  soon.  There  is  great  variation 
here  in  individual  children.  Some  children  mature  much  sooner  than  others 
and  are  ready  sooner  to  make  the  transition  from  school  to  work.  Methods 
must  be  developed  by  which  allowance  can  be  made  for  individual  variation. 


Health     and     Industry  581 

Considerable  antagonism  is  aroused  towards  the  present  regulation  of  children's 
work,  by  the  hardship  caused  in  individual  cases.  Even  though  hardship  in 
individual  cases  is  no  argument  for  the  abolition  of  restrictions  on  the  age  of 
children  going  to  work,  it  should  be  possible  to  originate  some  methods 
for  making  distinctions  in  individual  cases,  which  will  not  be  loopholes  for 
unscrupulous  and  destructive  evasion  of  the  laws  designed  to  protect  the 
health  and  best  interests  of  children.  Such  distinctions  can  be  worked  out  on 
the  basis  of  the  physical  ability  of  the  individual  child,  determined  after 
careful  medical  and  mental  examinations.  It  is  purposed  to  bring  out  the 
possibilities  of  such  a  method  in  the  following  sections. 

This  study  is  a  survey  of  the  present  relation  between  children  and  in- 
dustry in  Cleveland,  presenting  information  not  so  much  comprehensive,  as 
representative  of  the  situation.  The  regulations  limiting  children's  work 
which  are  at  present  in  force  are  considered  first,  and  next,  the  information 
which  has  been  available  regarding  the  number  of  children  at  work,  both 
legally  and  illegally.  Discussion,  in  some  detail,  of  the  kinds  of  work  in 
which  children  are  found  employed  follow.  The  questions  of  their  health  and 
the  measures  taken  to  safeguard  it  are  considered  separately.  There  is  included 
a  brief  report  on  the  mentally  subnormal  children  known  to  be  at  work. 
One  section  of  the  report  considers  the  relation  between  industrial  training, 
educational  preparation,  vocational  guidance,  and  health  and  efficiency.  The 
conclusions  reached  at  the  end  of  the  study  and  the  recommendations  made 
are  summarized  in  the  last  section. 

The  study  was  made  during  the  spring  of  1920.  It  had  been  the  inten- 
tion of  the  Consumers'  League  of  Ohio  to  make  some  such  research  into 
health  in  the  industrial  field  in  Cleveland.  Upon  hearing  the  comprehensive 
plans  contemplated  for  the  Hospital  and  Health  Survey,  the  Consumers' 
League  decided  to  support  the  services  of  a  special  worker  who  would  be  under 
the  direction  of  the  Survey,  rather  than  to  carry  on  an  independent  research. 
Such  an  arrangement  was  effected  for  the  present  study,  which  has  been 
made  by  a  member  of  the  staff  of  the  Industrial  Division  of  the  Hospital 
and  Health  Survey,  the  subject  of  Children  and  Industry  being  especially 
appropriate  to  the  long  continued  interest  of  the  Consumers'  League  in  work- 
ing children. 


LEGAL  PROVISIONS  FOR  CHILDREN  15  TO  18  GOING  TO  WORK 

In  order  to  understand  the  situation  as  it  is  in  Cleveland  for  children  of 
working  age,  a  review  of  the  existing  legislation  relating  to  children  of  this 
age  is  essential.  Who  are  children?  When  does  a  boy  become  a  man,  and 
a  girl  a  woman?  The  Ohio  Child  Labor  Law  says  that  a  girl  is  an  adult 
when  she  is  18,  and  may  work  the  same  hours  and  under  the  same  circum- 
stances as  any  woman,  save  that  she  cannot  work  at  night  until  she  is  21. 
According  to  the  Child  Labor  Law  a  boy  of  16  may  work  longer  hours  than 
an  adult  woman  may  work.  After  he  is  18  this  law  considers  him  a  man 
in  every  respect,  able  to  work  any  number  of  hours,  day  or  night,  and  under 
the  same  conditions  as  govern  men's  work. 


582  Hospital  and  Health  Survey 

Research  has  shown  that  boys  mature  more  slowly  than  girls,  but  the 
Child  Labor  Law  says  that  a  boy  may  go  to  work  a  year  earlier  than  a  girl, 
and  that  he  may  have  a  year's  less  schooling  than  a  girl. 

On  the  other  hand,  the  common  law  of  the  state  does  not  consider  a  boy 
a  man  until  he  is  21,  when  he  may  for  the  first  time  exercise  property  rights 
and  the  right  of  franchise,  and  get  a  marriage  license  without  permission  of 
his  parents  or  guardian. 

Following  is  a  summary  of  the  essential  provisions  of  the  Child  Labor  Law 
of  Ohio,  and  of  other  laws  relating  to  children  of  1.5  to  18  years  going  to 
work. 


Age  Requirements 

Employment  of  boys  under  15  and  girls  under  16  years  of  age  is  strictly 
forbidden.  iVge  and  schooling  certificates  are  required  for  all  boys  under  16 
and  all  girls  under  18  years  of  age. 

Boys  under  16  and  girls  under  18  years  of  age  may  not  legally  be  emdelrpo 
more  than  eight  hours  daily,  48  hours  weekly,  before  7  in  the  morning,  not 
after  6  in  the  evening,  nor  more  than  six  days  in  any  week. 

Boys  under  18  years  of  age  may  not  legally  be  employed  more  than  10 
hours  daily,  .54  hours  weekly,  before  6  in  the  morning  or  after  10  at  night, 
nor  more  than  six  days  in  any  week. 

Girls  between  18  and  21  years  of  age  may  not  legally  be  employed  more 
than  nine  hours  daily  (except  Saturday  in  mercantile  establishments,  when 
10  hours  is  the  limit),  .50  hours  weekly,  before  6  in  the  morning  and  after  10 
at  night,  nor  more  than  six  days  in  any  week. 

Certain  occupations  involving  physical  and  moral  hazard  are  prohibited 
for  all  women.  Girls  under  21  cannot  work  at  employment  involving  con- 
stant standing.  No  boy  or  girl  under  18  can  be  employed  at  extremely 
dangerous  occupations  to  health  and  morals,  eighteen  such  occupations  being 
specified  in  the  law.  Xo  boy  under  15  years  of  age  and  no  girl  under  16  years 
of  age  can  be  employed  at  all,  save  in  agricultural  work  or  in  domestic  service. 
Xo  boy  15  to  16  can  be  employed  at  dangerous  machinery  or  where  his  health 
may  be  injured  and  his  morals  depraved,  or  at  the  tobacco  trades.  Thirty- 
two  other  occupations  are  prohibited  to  boys  in  the  law. 


Educational  Requirements 

1 .  The  age  and  schooling  certificates  required  for  all  boys  15  to  16  years 
of  age,  and  all  girls  16  to  18  years  of  age  must  show  that  every  boy  has 
passed  a  sixth  grade  test,  and  that  every  girl  has  passed  a  seventh  grade  test. 
If  upon  examination  and  by  school  record  a  child  proves  to  be  below  the  nor- 
mal in  mental  development  and  unable  to  pass  this  test,  he  may  receive  a 
school  certificate  at  the  discretion  of  the  issuing  officer. 


Health     and     Industry  583 

2.  Every  boy  15  to  16  years  of  age  must  return  to  school  if  he  ceases 
work  and  does  not  find  other  work.  No  provision  is  made  requiring  girls 
16  to  18  to  return  to  school  if  not  at  work. 

Health  Requirements 

A  certificate  is  required  from  the  school  physician  or  some  properly  qual- 
ified physician  showing  that  a  child  is  physically  fit  to  be  employed  in  any  of 
the  occupations  permitted  by  law  for  a  child  between  15  and  16  years  of  age, 
provided  that  if  the  records  of  the  school  physician  show  such  child  to  have 
been  previously  sound  in  health,  no  further  physician's  certificate  need  be 
required. 

Special  Vacation  Certificate 

Boys  15  to  16  years  of  age  and  girls  16  to  18  years  of  age  may  have  vaca- 
tion certificates  to  be  employed  in  occupations  not  forbidden  by  law,  even 
though  they  have  not  passed  the  required  school  grade,  provided  all  other 
requirements  for  a  certificate  are  complied  with. 

Street  Trades 

No  provision  is  made  in  the  Ohio  State  Law  which  covers  street  trades. 
There  is  a  city  ordinance,  not  enforced,  regulating  this  kind  of  work.  This 
will  be  further  discussed  in  a  section  of  the  report  on  newsboys. 

Juvenile  Court 

Provision  is  made  through  the  Juvenile  Court  and  probation  system  for 
dealing  with  delinquent  young  people  of  all  ages  who  can  be  classed  as  juve- 
niles. The  offending  street  trader,  or  truant  from  school,  here  receives  less 
severe  handling  than  in  regular  law  courts,  and  is  dealt  with  by  persuasion 
rather  than  by  punishment. 

Enforcement  of  Present  Laws 

This  comes  under  the  School  Attendance  department  of  the  city  schools  and 
the  department  of  Factory  Inspection  of  the  State  Industrial  Commission. 
These  two  agencies  cooperate  to  keep  track  of  all  children  of  the  ages  in 
question.  The  adequacy  of  their  working  force  and  their  success  in  enforcing 
these  regulations  will  be  discussed  at  the  end  of  the  next  section. 


STATISTICS  FOR  CHILDREN  IN  INDUSTRY  IN  CLEVELAND,  1919 

There  are  three  sources  of  information  from  which  to  ascertain  how 
many  children  there  are  in  Cleveland,  of  what  age  and  of  what  sex,  how 
many  of  them  are  working  and  how  many  are  in  school. 

1.  The  school  census,  taken  every  spring  by  the  Census  Bureau  of  the 
Board  of  Education,  enumerates  each  child  in  the  city  from  6  to  20  years  of 
age,  whether  he  is  in  school,  out  of  school  or  at  work. 


.584  Hospital  and  Health  Survey 

2.  The  Industrial  Commission  of  Ohio  obtains  annually  from  all  employ- 
ers records  of  the  occupations  and  wages  of  all  boys  and  girls  under  18  whom 
they  employ. 

3.  The  work  certificate  office,  at  the  Board  of  Education,  keeps  on  file 
the  name,  age  and  sex  of  every  child  who,  after  complying  with  certain  re- 
quirements, secures  from  the  office  an  age  and  schooling  certificate,  which 
entitles  him  to  go  to  work. 

It  was  possible  to  obtain  information  from  these  three  sources  for  the 
same  period  of  time,  the  year  of  1919.  The  school  census  of  May,  1919,  was 
analyzed  so  as  to  obtain  information  for  boys  and  girls  separately,  the  records 
of  the  work  certificate  office  for  the  school  year,  September,  1918,  to  June, 
1919,  were  secured  and,  through  the  courtesy  of  the  Industrial  Commission, 
their  statistics  for  1919,  which  are  not  yet  published,  were  obtained  and 
analyzed. 

The  information  collected  in  this  way  for  the  number  of  children  at  work 
is  somewhat  surprising  to  compare.  Following  is  the  summary  of  results. 
The  full  tables  for  this  information  may  be  found  in  the  Appendix,  Tables 
XVI.  to  XVIII. 


TABLE  XIX. 

Comparison  of  Three  Tables  for  Number  of  Children  at  Work  ix 

Cleveland  in  1919. 

Boys  Girls  Total 

School  Census,  15-18  years  of  age..... .9,068  (15-18)  6,778  (16-18)  15,846 

Industrial  Commission  of  Ohio,  15-18  years  of 

age 1 2,957  (15-18)  2,072  (16-18)  5,029 

Work  Certificates  Issued,  15-16,  16-18  years  of 

age 1,444  (15-16)  2,057  (16-18)  3,501 

Of  the  three  records  probably  the  records  of  the  School  Census  more 
nearly  approximate  the  truth  as  to  the  number  of  children  actually  in  indus- 
try. Their  figures  were  obtained  in  a  house  to  house  canvass  of  the  whole 
city  and  were  then  checked  up  with  the  existing  school  records  at  the  Census 
Bureau  of  the  Board  of  Education,  where  a  school  child's  card  contains  as 
well,  a  record  of  the  whole  family  of  children,  whether  of  school  age  or  not. 
The  figures  of  the  Industrial  Commission  were  obtained  from  employers, 
and  it  may  well  be  that  they  recorded  only  the  certificated  children  whose 
permits  were  on  file  in  their  office,  which  would  be  boys  15  to  16  and  girls 
16  to  18  years  of  age.  The  boys  16  to  18  employed  are  only  estimated  in 
many  cases.  Not  all  employers  keep  age  records  of  their  employes.  Fur- 
thermore, the  Industrial  Commission  records  are  not  complete,  as  a  number 
of  employers  have  not  yet  made  their  reports  to  the  Commission  for  1919. 
The  work  certificate  office  figures  included  only  those  children  who  went  to 
work  through  the  legal  channels. 


Health     and     Industry  585 

4.     Illegal  Child  Labor  and  Law  Enforcement. 

Comparison  of  these  sets  of  figures  shows  the  great  extent  of  unlicensed 
labor  on  the  part  of  girls  16  to  18  years  of  age.  Almost  5,000  girls  are  at 
work  in  Cleveland  with  no  check  on  them  in  any  way  to  see  that  the  health 
and  educational  standards  considered  essential  for  them  are  maintained.  In 
addition,  these  figures  take  no  account  of  the  extent  of  work  among  children 
who  are  under  the  legal  age  for  employment.  Reports  have  come  in  on  all 
sides  as  to  the  number  of  under  age  children  who  are  at  work  regularly,  as 
well  as  at  work  part  time  after  school  and  on  Saturdays. 

It  has  been  exceedingly  difficult  to  verify  these  reports,  save  for  scattered 
individual  cases.  There  is  undoubtedly  truth  in  the  prevailing  opinion. 
The  school  census  bureau  is  freely  used  by  a  number  of  employers  to  verify 
the  ages  of  young  children  applying  for  work.  Records  were  kept  by  the 
school  census  bureau  office  for  several  weeks  of  such  calls  from  employers, 
and  disclosed  actually  at  work,  or  applying  for  work,  168  boys  and  girls  who 
were  under  the  legal  age  for  employment. 


Ages  and  Number  of  Children  Applying  for  Work 

Age  Boys  Girls 

11  1 

12  5 

13  25  13 

14  34  41 

15  1  48 

Total.  66  102—168 

42  of  the  boys  and  73  of  the  girls  were  regularly  at  work,  the  remaining  num- 
ber, 23  boys  and  28  girls,  had  applied  for  work.  22  employers  were  repre- 
sented in  this  list.  One  department  store  was  responsible  for  60  of  the  viola- 
tions, the  majority  of  which  were  for  girls,  and  one  manufacturer  of  metal 
products  was  responsible  for  18  violations,  most  of  them  for  boys.  The 
facility  with  which  these  figures  were  collected  is  an  indication  of  the  extent 
of  illegal  employment  of  children.  In  addition  must  be  reckoned  those  chil- 
dren working  after  school  and  on  Saturdays  without  permits. 

Some  of  these  children  had  been  out  of  school  for  months,  two  or  three 
as  long  as  two  years.  One  boy  had  been  injured  and  his  case  brought  into 
court.  Another  boy  of  15  was  working  with  a  paper  company  without  a 
permit.  An  accident  brought  this  case  to  the  notice  of  the  school  authori- 
ties. The  boy's  hand  was  crushed  in  a  machine.  His  school  record  showed 
him  to  be  defective,  of  a  mental  age  of  9  years  according  to  the  test.  If  this 
boy  had  gone  to  work  through  the  work  permit  office  where  his  physical  and 


.586  Hospital  and  Health  Survey 

mental  condition  would  have  been  determined,  his  employer  would  have 
been  notified  of  his  mental  disability,  and  the  boy  protected  from  an  accident 
hazard. 

The  Child  Labor  Law  of  Ohio  is  often  cited  for  its  excellence.  If  the  law 
is  not  enforced,  its  excellence  is  without  virtue. 

One  explanation  of  this  illegal  employment  is  to  be  found  in  the  depart- 
ments of  School  Attendance  and  of  Factory  Inspection.  For  it  is  their  joint 
responsibility  to  see  that  the  school  and  child  labor  regulations  are  enforced. 
Both  these  agencies  work  at  a  disadvantage.  One  truant  officer  must  keep 
track  of  10,000  children.  Boston  requires  one  attendance  officer  for  every 
6,000  children.  Obviously,  one  officer  cannot  cover  all  of  the  cases  of  irregu- 
lar attendance  which  occur  among  10,000  children.  As  it  is  now,  the  truant 
officers  devote  only  a  small  part  of  their  time  to  following  up  children  of 
working  ages.  If  a  child  has  come  into  the  office  and  obtained  a  permit  for 
a  job,  but  has  left  that  job,  the  permit  then  coming  back  to  the  office  from 
the  employer,  he  should  return  to  school.  This  is  not  followed  up.  No  one 
knows  what  becomes  of  the  child.  A  list  of  such  children  was  once  started 
but  the  list  grew  so  rapidly  that  it  was  impossible  for  the  attendance  officers 
to  keep  up  with  it,  so  the  matter  wras  dropped.  This  means  that  either  the 
children  are  not  working  and  are  not  in  school,  or  they  are  working  illegally 
without  a  permit. 

There  is  no  question  of  the  efficiency  of  the  present  force.  School  prin- 
cipals and  others  interested  have  spoken  most  highly  of  the  work  of  the 
attendance  department,  saying  that  the  officers  are  untiring  in  their  efforts 
and  most  cooperative.  With  such  a  small  force  something  has  to  be  neg- 
lected and  the  children  of  working  age  have  been  ready  to  take  advantage 
of  the  light  authority  imposed  on  them. 

This  situation  is  true  also  for  the  State  Department  of  Factory  Inspection 
of  the  Industrial  Commission.  There  are  for  the  88  counties  of  Ohio  eight 
women  visitors  to  see  to  the  enforcement  of  the  child  labor  law  and  others. 
The  several  counties  surrounding  and  including  Cleveland  have  the  full 
services  of  two  inspectors,  who  do  splendid  work,  but  who,  obviously,  could 
not  be  expected  to  be  responsib'e  for  full  enforcement  of  the  law.  Cleveland 
industry  alone  employs  tens  of  thousands  of  women  and  young  people  and 
needs  the  supervision  of  several  inspectors  in  order  that  industrial  plants 
may  be  visited  more  than  once  annually. 

Undoubtedly  one  source  of  illegal  child  labor  is  the  tremendous  labor 
shortage  which  has  prevailed  throughout  the  present  year.  This  shortage  was 
mentioned  almost  without  exception  by  every  employer  visited.  "We 
can't  get  help.  Ordinarily  our  rule  is  never  to  employ  anyone,  boy  or  girl, 
under  18.  But  we  have  been  forced  to  make  exceptions  to  this  rule  because 
we  can't  get  enough  help  otherwise." 

The  attitude  of  foreign  parents  is  antagonistic  also.  They  wish  their 
children  to  go  to  work  as  soon  :\s  possible  and  will  resort  to  any  subterfuge 


Health     and     Industry  587 

in  order  to  evade  the  law.  It  should  be  pointed  out  that  economic  necessity 
is  by  no  means  always  the  explanation  of  their  attitude.  Foreigners  have  a 
different  attitude  toward  their  children  from  that  of  most  Americans.  Chil- 
dren represent  so  much  potential  earning  power  which  must  be  utilized  for 
the  family  income  at  the  earliest  possible  time.  The  sense  for  property, 
owning  a  home,  is  strongly  developed  in  European  peasant  people,  and  they 
will  make  every  sacrifice  of  themselves  and  even  of  their  children,  in  order 
to  acquire  a  little  land  and  a  house,  having  no  thought  for  the  possible  physi- 
cal harm  they  are  bringing  on  themselves.  The  strong  constitution  which  is 
the  inheritance  of  the  European  peasant  does  not  always  endure  for 
his  children.  Life  in  an  American  city  offers  less  opportunity  for  the  de- 
velopment of  a  rugged  physique  able  to  withstand  heavy  toil  as  well  as  the 
high  power,  top-speed  existence  characteristic  of  city  life. 

Extension  of  school  hygiene  and  general  health  education  will  in  time 
eliminate  this  attitude  on  the  part  of  parents  towards  their  children.  But 
meanwhile  the  laws  designed  to  conserve  the  health  and  welfare  of  children 
are  the  only  defense  available  to  protect  them  from  their  own  ignorance  and 
the  ignorance  or  short-sightedness  of  their  parents  or  employers. 

But  one  of  the  principal  causes  of  so  much  illegal  employment  of  children 
is  the  fact  that  the  children  know  they  "can  get  away  with  it."  Otherwise 
there  would  never  be  so  many  applications  for  work  from  such  young  chil- 
dren. Inadequate  supervision  on  the  part  of  the  truant  officers  on  one  hand 
and  of  the  Factory  Inspection  Department  on  the  other,  leaves  too  many 
loopholes  for  children  to  slip  through. 

If  it  is  impossible  to  enforce  these  laws  with  the  present  organization 
and  personnel  of  the  school  and  state  departments,  then  their  methods  should 
be  improved  and  their  personnel  increased  to  cover  the  city  adequately. 
No  city  of  the  size  and  importance  of  Cleveland  can  afford  to  allow  large 
numbers  of  its  children  of  the  ages  of  12  to  16  years  to  enter  industry,  unre- 
stricted and  undirected,  their  physical  fitness  to  perform  the  tasks  which 
they  pick  out  for  themselves,  in  no  way  ascertained,  nor  their  capacity  to 
stand  up  under  continued  years  of  industrial  life  assured  in  any  degree. 

More  supervision  must  be  provided  both  by  the  school  authorities  and 
by  the  State  Industrial  Commission,  in  order  to  check  up  on  this  illegal 
employment.  This  is  vital.  No  prerequisite  health  standards  for  children 
at  work  can  be  established  and  maintained  until  it  is  certain  that  every 
child  going  to  work  goes  through  the  work  permit  office,  where  he  is  medi- 
cally examined  and  must  show  physical  fitness  before  he  can  obtain  a  permit 
for  employment. 

It  is  recommended  that  at  least  three  more  women  inspectors  be  assigned 
to  the  Cleveland  district  by  the  State  Industrial  Commission  and  that  the 
number  of  attendance  officers  in  the  School  Attendance  Department  be  in- 
creased from  13,  the  present  number,  to  at  least  °2(). 


•588  Hospital  and  Health  Survey 

WHERE  CHILDREN  WORK 

1.     Occupations  Employing  Children 

Boys  and  girls  are  employed  in  greatest  numbers  in  manufacturing,  retail 
and  wholesale  trade,  and  in  telephone  and  telegraph  work.  Table  XX.  in  the 
Appendix  shows  the  distribution  of  boys  and  girls  in  the  various  trades,  as 
shown  in  the  Industrial  Commission's  report.  As  before  stated,  the  statistics 
of  the  Industrial  Commission  are  not  numerically  complete,  but  they  are 
sufficiently  extensive  to  be  representative  of  trades  employing  children  in 
Cleveland.  The  information  obtained  through  personal  visits  to  50  different 
establishments  employing  children  in  some  numbers,  corroborates  in  every 
instance  the  evidence  of  the  Industrial  Commission's  figures. 

The  last  published  report  of  employment  by  the  Industrial  Commission 
of  Ohio  for  Cleveland  is  for  the  year  of  1915.  A  total  of  3,299  children  under 
18  were  employed  in  that  year,  as  against  5,029  employed  in  1919,  showing 
an  increase  of  about  1,800  in  four  years,  or  35%.  Table  XXI.  in  the  x^ppendix 
shows  the  distribution  of  children  in  the  various  trades  for  these  two  years, 
1915  and  1919.  There  are  several  noteworthy  changes.  Telephone  and  tele- 
graph work  in  1919  used  463  girls  under  18.  In  1915, 35  girls  were  so  employed. 
On  the  other  hand,  the  employment  of  young  girls  has  fallen  off  considerably 
in  the  manufacture  of  clothing,  hosiery  and  knit  goods,  and  woolen  and 
worsted  goods.  The  employment  of  boys  has  increased,  mainly,  in  the 
manufacture  of  electrical  machinery,  foundry  and  machine  shop  products 
and  sewing  machines.  Their  employment  has  decreased  in  steel  works  and 
rolling  mills.  Both  boys  and  girls  are  employed  in  greater  numbers  now  in 
the  retail  and  wholesale  trade  than  in  1915. 

The  largest  numbers  of  both  boys  and  girls  are  employed  in  manufactur- 
ing, in  round  numbers  3,000  boys  and  900  girls.  The  majority  of  these  are 
wage  earners,  as  distinguished  from  clerical  workers.  This  is  true  of  all 
employment  for  children.  The  classification  of  the  Industrial  Commission 
includes  three  groups  of  employes:  clerical  workers,  wage  earners  and  sales 
people.  23.7%  of  all  children  accounted  for  are  clerical  workers,  72.8%  are 
wage  earners  and  3.5%  are  sales  people. 

Boys  and  girls  are  scattered  throughout  the  manufacturing  trades,  being- 
found  in  greatest  numbers  engaged  in  the  manufacture  of  men's  and  women's 
clothing,  hosiery  and  knit  goods,  the  metal  trades  and  printing  and  publish- 
ing. 39  manufacturing  establishments  were  visited.  In  all,  50  establish- 
ments employing  young  people  were  visited  and  information  collected  re- 
garding hours,  wages,  nature  of  work,  opportunity  for  advancement,  educa- 
tional requirement,  medical  service  and  general  conditions  of  work.  The 
opinion  of  each  employer  was  obtained  as  to  the  employment  of  junior  help. 

Medical  service  is  described  in  detail  in  the  first  section  of  the  Industrial 
Survey  report,  andconditions of  work  in  the  second  section,  therefore,  no  further 
discussion  will  be  made  of  these  two  subjects  in  this  report.  In  all  places 
where  girls  are  found  at  work  women  are  employed  as  well,  and  conditions 


Health     and     Industry 


589 


of  work  are  identical  for  both.  This  does  not  apply  equally  to  boys.  It 
must  be  remembered,  as  pointed  out  earlier  in  the  report,  that  boys  do  not 
work  under  the  same  supervised  conditions  of  work  which  the  law  insists  upon 
for  women  and  girls.  Boys  must  use  those  toilet  and  dressing  room  facilities 
which  are  provided  for  the  men,  and  must  eat  their  lunch  under  the  same 
circumstances  that  men  do.  This  often  means  a  cold  lunch.  While  many 
factories  provide  a  cafeteria  where  girls  and  women  may  obtain  a  hot  lunch, 
not  all  of  them  provide  the  same  service  for  boys  and  men. 


A.     Hours  of  Work 

The  law  limits  the  hours  of  work  of  boys  15  to  16  and  girls  16  to  18  years 
of  age,  to  8  daily  and  48  weekly.  So  far  as  it  was  possible  to  ascertain  the 
facts  on  this  point,  the  law  is  observed.  Employers  who  wish  to  use  the 
services  of  children,  find  no  difficulty  in  arranging  their  schedule  of  hours  to 
accommodate  an  eight-hour  shift  for  the  children.  Employers  who  can  get 
along  without  the  services  of  children  state  that  they  employ  no  one  under 
18,  because  of  the  difficulty  of  arranging  a  separate  8-hour  shift. 


B.     Wages 

Table  XXII.  in  the  Appendix  shows  the  rates  of  wages  paid  to  children  in 
all  occupations.  2,635  of  5,029  children  listed  by  the  Industrial  Commission 
report  receive  from  $10  to  $15  weekly.  648  children  receive  less  than  $10 
weekly.  Figures  obtained  by  visits  in  the  spring  of  1920  run  very  slightly 
higher,  22  establishments  pay  between  $13  and  $15  weekly,  18  establishments 
pay  $15  or  more  weekly  and  15  establishments  pay  less  than  $13  weekly.  In 
all  cases  where  employers  were  questioned  as  to  wages,  the  beginning  rate 
has  been  quoted,  as  the  character  of  the  information  for  regular  wage  rates 
varies  greatly.  Some  employers  use  hourly  rates,  others  weekly,  some  esti- 
mate wages  on  a  piece  work  basis,  and  others  use  a  straight  time  rate.  Even 
a  payroll  would  not  give  exact  figures,  for  the  result  of  the  labor  scarcity  of 
the  past  few  months  has  been  to  make  labor  very  independent,  working  only 
a  few  days  in  one  place,  or  at  one  time.  As  one  employer  said  when  inter- 
viewed, "The  girls  come  and  go  as  they  please.  I  don't  dare  say  anything, 
or  they  put  on  their  hats  and  leave.     All  I  do  is  to  carry  the  key." 

Wage  rates  are  slightly  lower  in  retail  and  wholesale  trades,  and  very 
definitely  so  in  telephone  and  telegraph  work,  where  the  rate  is  $10  to  $12 
weekly.  Manufacturing  pays  more,  especially  to  boys.  More  boys  receive 
from  $15  to  $21  per  week  than  from  $10  to  $15  per  week.  Wages  for  boys 
are  generally  higher  than  for  girls.  This  is  true  of  all  occupations.  The 
present  wages  paid  to  boys  in  the  various  shops  classed  under  metal  trades 
work  have  been  so  high  as  to  make  boys  a  scarcity  in  all  other  kinds  of  work 
open  to  them.  On  the  whole  wage  rates  for  children  are  high,  due  to  the 
fact  that  many  children  are  doing  adults'  work  because  of  the  labor  shortage. 


590  Hospital  and  Health  Survey 

C.     Nature  of  Work  and  Opportunity  for  Advancement 

These  vary  in  almost  every  trade  for  boys  and  girls.  In  the  industrial 
held  proper  the  manufacture  of  men's  and  women's  clothing  offers  to  girls 
good  opportunity  to  learn  a  trade  and  advance  to  higher  positions.  Boys 
in  this  trade  run  errands,  or  work  in  the  shipping  room.  Their  greatest 
chance  for  a  job  with  some  future  is  to  become  an  apprentice  to  a  cutter.  In 
the  six  establishments  visited,  girls  learn  the  trade  in  a  school  maintained 
in  the  factory  or  from  instructors,  and  require  from  two  to  eight  weeks  in 
which  to  learn.  They  may  start  in  at  once  on  power  machine  operating  or 
begin  by  examining  or  packing  the  finished  product.  One  instructor  states 
that  young  girls  are  not  strong  enough  to  do  machine  work  and  so  are  started 
in  on  hand  work.  The  sewing  trades  offer  a  very  good  opportunity  to  girls. 
Girls  should  be  carefully  watched,  however,  against  undue  eyestrain.  One 
factory  has  the  eyes  of  girls  regularly  examined  by  an  oculist,  and  insists  on 
glasses  being  obtained  if  prescribed.  The  physical  condition  of  each  girl 
should  be  determined  before  she  is  allowed  to  begin  power  machine  operat- 
ing. This  could  be  done  by  the  company  physician  or  by  the  examining 
physician  at  the  office  where  she  obtains  her  permit  to  work,  and  a  recom- 
mendation put  on  her  permit  as  to  her  physical  ability  to  essay  heavy  work. 


The  Manufacture  of  Confectionery 

This  is  a  seasonal  industry  and  attracts  girls  of  the  floater  type  who  never 
stay  very  long  anywhere,  or  who  wish  to  work  only  occasionally  and  do  not 
wish  to  work  where  they  have  to  spend  time  learning  a  trade.  Chocolate 
dipping  is  the  only  operation  for  women  in  this  trade  requiring  any  skill, 
and  very  few  of  the  younger  girls  are  found  at  chocolate  dipping.  The  em- 
ployment of  boys  in  this  trade  is  negligible. 


The  Manufacture  of  Hosiery  and  Knit  Goods 

This  industry  employs  boys  and  girls  in  about  equal  numbers.  In  most 
instances  it  is  no  longer  a  seasonal  industry.  The  work  is  easy  to  learn  and  in- 
struction is  given  by  other  workers  or  by  foreladies.  Some  of  the  boys  and  girls 
work  on  knitting  machines,  but  most  of  them  handle  the  finished  product  in  the 
stock  room,  doing  inspecting,  folding  and  packing.  In  addition,  boys  are  em- 
ployed to  run  errands.  There  is  little  or  no  opportunity  for  advancement  in  this 
kind  of  work.  An  increase  in  wages  is  the  most  that  can  be  hoped  for. 
Considerable  standing  is  necessary.  The  law  states  that  no  girl  under  21 
shall  be  employed  at  an  occupation  requiring  her  to  stand  constantly,  and 
that  seats  must  be  provided  for  every  girl  and  woman  employed.  Seats 
are  usually  provided  and  sometimes  made  use  of.  The  average  girl  needs 
instruction  in  health  education.  Some  standing  is  necessary  in  all  occupa- 
tions, but  many  employes  stand  constantly,  even  though  their  work  does 
not  require  it.  On  the  other  hand,  many  tasks  are  done  standing  which 
could  be  done  seated,  if  employers  would  devote  a  little  thought  to  the  mat- 
ter. Numerous  machines  are  now  operated  from  seats,  which  formerly  re- 
quired a  standing  position.     It  is  very  essential  to  the  health  of  young  girls 


Health     and     Industry  591 

that  they  be  not  subjected  to  the  strain  of  continued  standing.  No  small 
function  of  the  medical  service  in  industrial  plants  should  be  the  instruction 
of  employes,  especially  the  younger  ones,  in  the  application  of  common  sense 
to  their  daily  living,  in  such  matters  as  alternate  sitting  and  standing  at 
work,  changing  of  posture  while  at  work,  the  wearing  of  practical  working- 
clothes  which  will  give  freedom  of  movement  and  the  maximum  of  comfort, 
the  necessity  for  nourishing  diet,  plenty  of  sleep,  fresh  air,  and  other  related 
subjects. 


The  Metal  Trades 

Of  the  23  metal  trades  establishments  visited,  nine  employed  boys  and  a 
few,  girls.  294  boys  and  9  girls  under  18  were  found  at  work.  The  girls 
were  for  the  most  part  engaged  in  packing  and  sorting  parts  and  in  making 
small  pasteboard  boxes.  In  no  case  was  their,  work  difficult  and  in  every 
case  they  were  seated  at  benches.  For  boys  the  metal  trades  offer  exception- 
ally good  opportunities  for  learning  a  skilled  trade.  In  eight  of  the  nine 
plants  they  were  found  working  in  machine  shops  under  the  supervision  of 
skilled  workmen,  making  good  pay  and  having  every  chance  to  apply  them- 
selves and  get  ahead.  Very  few  of  these  boys,  however,  were  under  16  years 
of  age.  Employers  almost  universally  stated  that  it  was  their  rule  to  employ 
no  boys  under  16.  "They  are  a  nuisance."  Much  of  the  machinery  involves 
too  great  an  accident  hazard  for  such  young  boys,  and  there  is  nothing  much 
they  can  do  but  run  errands.  Even  boys  from  16  to  18  years  of  age  are  looked 
upon  with  disfavor.  Whatever  the  explanation  may  be,  it  is  true  that  the 
dissatisfaction  of  employers  with  boys  of  this  age  is  general.  "They  are 
hard  to  get  and  no  good."  A  number  of  firms  were  visited  which  had  been 
known  to  employ  boys  of  this  age,  but  no  longer  do  so,  having  made  a  strict 
rule  to  employ  no  one  under  18,  boys  or  girls,  because  they  had  proved  to  be 
such  unsatisfactory  help.  As  a  group,  the  metal  trades  seem  to  be  above 
the  average  in  plant  organization  for  the  welfare  of  employes.  Medical 
service  is  provided,  equipment  is  good,  hot  food  nlay  be  obtained  at  noon, 
and  some  recreation  is  provided.  This  is  well  worth  noting  because  of  the 
large  number  of  boys  it  affects.  1,119  of  the  2,090  boys  employed  in  indus- 
try proper  in  Cleveland  are  in  the  metal  trades. 

In  the  plants  visited  115  of  the  boys  were  employed  as  apprentices.  This 
means  that  they  were  systematically  learning  a  machinist's  trade  and  in  addi- 
tion were  occupied  part  of  each  week  in  study  and  class  work,  either  at  East 
Technical  High  School  or  in  classes  conducted  in  the  plant.  The  superi- 
ority of  this  method  of  inducting  boys  into  industry  cannot  be  emphasized 
too  strongly.     It  will  be  discussed  in  more  detail  in  a  later  section. 

There  are  only  a  few  shops  in  Cleveland  where  a  modern  or  in  fact  any 
system  of  apprenticeship  is  now  made  use  of.  A  number  of  employers  stated 
that  they  have  plans  for  it  in  mind,  but  that  with  the  present  scarcity  of 
boys,  it  is  not  possible  to  establish  such  a  system  now.  In  the  two  plants 
where  an  apprenticeship  system  is  well  established,  great  satisfaction  was 
expressed  as  to  the  results  obtained. 


.592  Hospital  and  Health  Survey 


Printing  and  Publishing 

This  is  a  trade  which  is  largely  unionized  in  all  its  branches,  even  in  the 
binderies,  which  make  use  of  girls  and  women.  For  girls,  in  practically  all 
work  done  by  them  outside  of  the  binderies,  there  is  no  job  with  a  future. 
Feeding  presses  is  the  commonest  sort  of  a  job.  This  is  easy  work,  is  safe, 
is  done  sitting,  but  is  very  monotonous.  Employers  frankly  say  that  it  is 
blind  alley  work  and  it  is  very  difficult  to  hold  girls  at  it  any  length  of  time. 

Boys  have  always  the  chance  to  learn  the  printer's  trade  or  to  become 
pressmen.  This  work  they  may  learn  through  the  apprenticeship  system 
which  is  directed  by  union  rules.  Union  rules  require  four  years'  time 
spent  as  an  apprentice  before  a  boy  is  able  to  qualify  as  a  skilled  worker. 
Non-union  shops  claim  that  the  work  can  be  learned  in  a  year  and  a  half. 
Union  rules  require,  in  the  case  of  pressmen,  that  there  can  be  only  one 
apprentice  to  every  five  pressmen  in  a  shop.  The  employer  in  this  trade 
states  that  there  should  be  an  allowance  of  one  apprentice  to  every  three 
pressmen  in  a  shop.  As  the  union  rule  works  out,  it  is  difficult  for  a  boy  jto 
become  an  apprentice,  as  there  are  few  openings.  No  relation  is  made  be- 
tween school  and  shop.     No  part  of  the  boy's  time  is  spent  in  class  work. 

Working  conditions  in  the  printing  trades  are  fair.  There  are  definite 
lead  hazards  in  most  branches  of  the  trade,  and  as  yet  union  organization 
has  not  recognized  this  hazard  in  relation  to  young  boys  who  are  especially 
susceptible  to  lead  poisoning.  No  provisions  are  made  to  protect  boys  from 
a  lead  hazard.  In  European  countries  boys  are  not  permitted  to  work  in 
occupations  which  expose  them  to  lead  fumes  or  dust.  Boys  in  American 
shops  have  been  found  doing  the  dustiest  kind  of  work,  cleaning  and  brushing 
linotyps  machines  and  gathering  up  lead  scraps.  Under  section  13337-4 
of  the  State  Child  Labor  Law  the  State  Board  of  Health  has  power  to  forbid 
the  employment  of  boys  under  18  at  any  process  injurious  to  their  health. 
This  authority  should  be  used  to  exclude  boys  from  employment  on  those 
processes  in  the  printing  trades  involving  a  lead  hazard. 


Retail  and  Wholesale  Trade 

Seven  large  department  stores  were  visited.  In  this  group  105  boys  and 
-266  girls  under  18  are  at  work.  They  are  apparently  employed  in  about 
equal  numbers.  Here  again  opportunity  differs  for  boys  and  girls.  Boys 
are  employed  in  the  stock  room  as  messengers  and  as  "jumpers"  and  wagon 
boys  in  the  delivery  department.  Many  boys  who  are  still  in  school  engage 
in  this  kind  of  work  after  school  and  on  Saturdays.  This  is  not  difficult 
work  for  an  active  boy.  It  is  done  in  good  surroundings,  for  the  most  part. 
The  modern  department  store,  of  which  there  are  a  number  in  Cleveland, 
serves  hot  meals  and  uses  care  and  thought  in  arranging  for  the  welfare  of 
its  employes.  The  chief  objections  to  this  kind  of  work  for  boys  are  that  it 
does  not  get  anywhere  in  giving  training  for  a  trade,  and  the  law  regulating 
the  hours  of  work  for  young  boys  is  often  disregarded  in  the  delivery  service. 
It  is  common  experience  to  have  a  package  thrust  in  a  house  door  late  in  the 
evening  by  a  small  boy,  especially  on  Saturdays  and  in  a  holiday  season. 


H  E  A  LTH      AND      INDUSTRY  593 

Girls  are  welcomed  into  department  store  organization  very  readily.  One 
employer  says,  "We  cannot  get  along  without  our  junior  help."  Another 
says,  "We  give  careful  attention  to  the  young  girls  coming  to  work  for  us, 
for  in  them  we  look  for  our  future  material  for  salesmanship."  At  least  four 
of  the  stores  visited  have  an  educational  department,  where  girls  receive  a 
certain  amount  of  class  instruction  as  training  for  store  work.  Girls  under 
18  rarely  start  in  as  saleswomen.  They  are  employed  as  branch  cashiers, 
as  wrappers  and  in  inspecting  merchandise.  In  time  they  may  graduate 
into  salesmanship  work,  where  there  is  greater  opportunity  both  in  salary 
and  for  responsible  positions.  The  New  York  State  Factory  Investigating 
Commission  considers  there  is  a  definite  health  hazard  for  young  girls  in 
much  of  department  store  work.  "The  nervous  tension  of  the  work  of  parcel 
wrappers  and  of  floor  cashiers  has  been  found  to  be  of  a  serious  character." 


Telephone  and  Telegraph  Work 

Telephone  Work. 

About  400  girls  under  18  are  employed  in  telephone  work.  This  is  a 
marked  increase  over  the  number  in  1915,  when  only  35  girls  were  listed  for 
both  telephone  and  telegraph  work.  The  telephone  companies  have  in  the 
past  endeavored  to  limit  employment  to  girls  over  18,  but  their  inability  to 
get  sufficient  operators,  with  the  resulting  unsatisfactory  telephone  service, 
has  led  them  to  seek  younger  girls.  . 

No  report  of  the  trade  of  telephone  operating  can  be  made  without  careful 
consideration  of  the  nature  of  the  work.  Telephone  officials  stoutly  insist 
that  there  is  no  nervous  strain  in  operating,  that  it  is  pleasant  and  healthful 
work.  Some  of  them  base  this  statement  on  their  own  experience  of  years 
in  the  service.  And  in  appearance  these  women  justify  their  contention. 
However,  in  comparison  with  other  types  of  work  open  to  girls  there  is  con- 
siderable difference.  Girls  work  in  "tricks"  of  four  hours;  having  during 
that  time  one  15-minute  relief  period,  when  they  can  leave  the  switchboard. 

This  15-minute  relief  period  is  a  regular  part  of  the  routine.  However, 
when  a  supervisor  is  short  of  workers  it  is  not  infrequently  impossible  for 
her  to  arrange  this  relief  period.  The  rest  of  the  four-hour  period  operators 
must  sit  steadily  in  one  position  before  the  switchboard.  There  is  no  op- 
portunity for  them  to  move  around  and  change  their  physical  position,  as  is 
the  case  in  most  other  occupations.  During  this  period  girls  are  sitting  with 
their  arms  stretched  out  before  them  or  reaching  upward,  and  their  eyes 
must  be  continually  on  the  switchboard.  White  and  colored  lights  are  con- 
tinually winking  on  this  board  in  front  of  them.  In  addition,  operators 
must  listen  and  talk  against  the  constant  buzz  and  noise  created  by  a  large 
number  of  people  talking  in  one  room,  even  though  the  noise  from  talking 
has  been  scientifically  reduced  to  a  minimum  by  the  construction  of  the 
switchboard  mechanism.  While  the  noise  in  the  operating  room  of  all 
exchanges  does  not  compare  with  the  roar  in  the  average  machine  shop,  the 
difficulty  is  that  in  a  telephone  exchange  almost  continuous  conversation  is 
necessary   with   subscribers,   requiring  close   and   sustained   attention   from 


594  Hospital  and  Health  Survey 

operators.  It  is  often  difficult  for  a  subscriber  to  retain  his  poise  and  calni 
during  a  fifteen  minute  period  of  telephone  communication.  How  much 
more  exacting  it  is  to  expect  the  same  of  an  operator  for  four  hours  at  a  time. 

Telephone  work  is  learned  in  a  training  school,  requiring  attendance  from 
two  weeks  upwards,  part  of  which  time  is  spent  in  the  class  room,  and  part 
at  the  switchboard.  A  salary  is  paid  to  the  student  while  attending  school. 
The  same  excellent  lunch  and  rest  room  facilities  are  provided  for  students 
as  for  regular  operators. 

There  is  good  opportunity  for  advancement  to  supervisory  positions  for 
a  girl  who  likes  telephone  work  and  will  continue  in  it.  There  is  also  con- 
siderable opportunity  in  the  commercial  field  for  private  branch  exchange 
operators.  This  kind  of  work  pays  well  and  often  leads  to  other  opportuni- 
ties. 

The  average  duration  of  service  of  telephone  workers  is  not  long.  Sta- 
tistics for  Cleveland  are  not  available  on  this  point,  beyond  the  statement  of 
officials  that  their  labor  turnover  is  high.  However,  in  the  report  on  tele- 
phone work  just  made  public  by  the  New  York  State  Industrial  Commission, 
it  is  stated  that  of  every  three  applicants  registered  for  telephone  training 
one  does  not  finish  training,  one  stays  less  than  one  year,  and  one  stays  more 
than  one  year.  As  a  girl  is  an  expense  to  the  company  until  she  has  been 
employed  one  year,  this  means  that  the  loss  on  operators  is  high.  The 
telephone  companies  make  every  effort  to  cut  down  the  high  labor  turnover 
by  means  of  careful  selection  of  operators,  improved  conditions  of  work 
and  well  developed  welfare  features.  That  the  rapidly  shifting  working- 
force  may  be  due  to  the  exacting  nature  of  telephone  operating  seems  not 
to  have  been  so  carefully  considered.  While  medical  service  is  provided  for 
all  plants  of  the  companies,  it  is  not  adequate.  The  facilities  of  the  medical 
department  should  be  expanded  to  give  operators  a  periodical  as  well  as  an 
initial  physical  examination,  and  complete  medical  records  should  be  main- 
tained, in  order  to  obtain  reliable  information  as  to  the  degree  of  nervous 
strain  experienced,  and  its  effect  on  the  health  and  efficiency  of  operators. 

•  That  there  is  a  distinct  health  hazard  in  telephone  work  for  younger  girls 
seems  undoubted.  Up  to  the  age  of  18  years  a  girl's  nervous  organism  is 
none  too  stable  in  any  case,  and  it  is  questionable  whether  it  should  be  sub- 
jected to  the  peculiar  nervous  strain  of  telephone  operating  in  an  urban 
community.  The  Ohio  Child  Labor  Law  prohibits  to  girls  under  18  certain 
occupations  dangerous  to  their  health.  It  is  recommended  that  a  careful 
study  be  made  of  the  effects  on  the  health  of  young  girls  of  this  kind  of  work, 
and  that  if  the  results  of  this  study  warrant  it,  telephone  operating  be  included 
in  the  occupations  forbidden  to  girls  under  18  years  of  age.  As  the  tele- 
phone companies,  in  Cleveland  as  well  as  elsewhere,  are  coming  to  rely 
more  and  more  on  the  services  of  younger  girls,  this  is  a  question  which  should 
have  immediate  attention. 


Health     and     Industry  595 

Telegraph  Work. 

As  organized  in  Cleveland  at  the  present  time  telegraph  work  has  few 
places  for  girls  under  18  years  of  age.  The  only  work  open  to  them  is  mes- 
senger work  in  the  operating  room.  When  a  girl  becomes  18  years  old,  howr 
ever,  she  may  go  the  company  school  and  take  a  several  weeks'  course  in  tele- 
graph operating.  There  is  in  this  work  a  trade  with  some,  if  not  a  consider- 
able future,  and  it  involves  no  great  health  hazard. 

Telegraph  business  makes  use  of  boys  in  large  numbers,  140  being  em- 
ployed as  messengers  by  the  two  companies  in  Cleveland.  Their  work  is 
easily  learned,  familiarity  with  the  city  being  about  the  only  requirement. 
There  is  no  real  opportunity  for  advancement  in  messenger  work.  A  boy 
might  better  make  his  initial  contact  with  the  industrial  and  commercial 
world  through  a  job  holding  out  some  inducement  to  buckle  down  and  learn 
a  trade.  Messenger  work,  like  newspaper  selling,  can  be  done  and  is  suc- 
cessfully in  one  company,  by  older  men.  Employers  like  the  energy  and 
hustle  native  to  youth,  but  it  is  short-sighted  to  allow  that  energy  to  be 
dissipated  in  a  job  without  a  real  future. 


D.     Educational  Requirement 

Throughout  the  trades  there  is  no  educational  requirement,  save  in  the 
case  of  apprentice  schools,  when  a  boy  must  have  graduated  from  the  8th 
grade.  The  last  group  described,  including  telephone  and  telegraph  work, 
endeavors  to  maintain  an  8th  grade  requirement.  Their  need  for  workers 
does  not  always  allow  them  to  do  so.  Possibly  the  most  striking  comment 
which  can  be  made  upon  the  various  tasks  at  which  girls  under  18  and  boys 
under  16  are  employed  is  that  the  mentally  subnormal  children  found  at 
work  in  the  city  almost  without  exception  are  engaged  at  the  same  tasks, 
upon  which  normal  children  are  working.  Apparently  the  tasks  are  so 
simple  that  it  is  possible  for  subnormal  children  to  engage  in  them  without 
difficulty.  The  work  is  easily  learned.  Few  of  the  jobs  upon  which  the 
younger  people  are  now  employed  require  any  great  skill.  From  the  stand- 
point of  learning  a  trade  this  is  not  always  objectionable.  For  example, 
in  department  store  work  there  are  a  variety  of  tasks  for  girls  to  become 
familiar  with,  no  one  of  which  requires  any  great  skill  for  proficiency,  but  all 
contributing  to  a  knowledge  which  is  essential  to  the  higher  jobs  opening  up 
to  girls  later  on  in  the  profession.  The  same  may  be  said  of  metal  trades  for 
boys.  There  is  considerable  preliminary  work  upon  which  a  boy's  time 
may  be  spent,  which  provides  general  training  for  machine  shop  work  and 
which  does  not  waste  his  time. 

From  the  standpoint  of  learning  a  trade,  it  is  objectionable,  however,  to 
employ  a  boy  or  girl  at  work  which  utilizes  youthful  energy  without  yielding 
any  training  for  future  competency.  The  messenger  work  at  which  so  many 
boys  and  some  girls  are  employed  in  factories  merely  uses  young  legs  because 
they  are  quicker  than  old  ones,  and  so  long  as  a  man  has  at  his  disposala 
pair  of  young  legs  it  is  easier  to  use  them  than  to  think  up  some  means  of 


596  Hospital  and  Health  Survey 

getting  along  without  them.  The  use  of  messenger  and  office  boys  is  a 
holdover  from  the  older,  more  inefficient  methods  of  doing  business  when 
work  was  conducted  without  thought  for  the  most  economical  organization 
of  time  and  energy.  In  the  labor  shortage  in  Cleveland  of  the  past  spring, 
the  job  that  was  the  hardest  hit  was  that  of  office  boy.  It  was  the  universal 
complaint  that  it  was  impossible  to  get  an  office  boy,  even  when  a  largely 
increased  salary  was  offered  as  inducement.  When  opportunity  was  open 
for  other  work,  boys  chose  the  job  of  office  boy  and  messenger  last  of  all. 


E.     Comments  of  Employers 

Opinion  differed  somewhat  as  to  the  merits  of  boys  and  girls  under  18. 
It  was  almost  universally  stated  that  the  boy  of  certificate  age,  that  is, 
15  to  16,  would  be  better  off  in  school.  Many  employers  thought  all  children 
under  18  were  better  off  in  school,  but  so  long  as  it  was  possible  to  do  so, 
they  employed  a  few.  A  number  stated  that  they  intended  to  eliminate 
the  younger  help  as  fast  as  possible. 

F.     Conclusions 

The  trend  of  the  comments  of  employers  strengthens  the  conclusions 
reached  after  the  study  of  children's  employment,  a  brief  summary  of  which 
is  recorded  in  the  observations  made  on  the  various  occupations.  These 
conclusions  are  first,  that  the  presence  of  boys  of  15  to  16  years  of  age  in 
industry  is  not  necessary  and  can  and  should  be  eliminated;  and,  second, 
that  there  must  be  more  conscious  direction  into  the  industrial  field  of  boys 
and  girls  16  to  18.  The  blind  way  in  which  the  average  boy  or  girl  gets  his 
or  her  first  job  is  one  reason  for  their  employment  at  casual  work,  learned 
today  and  forgotten  tomorrow.  Their  work  is  unsatisfactory  and  they  are 
unreliable  because  there  is  nothing  about  their  jobs  to  wake  them  up  to 
real  effort.     Their  minds  are  elsewhere. 

Blind  alley  jobs  in  children's  employment  have  been  recognized  for  some 
time,  and  while  not  approved  have  been  more  or  less  condoned  as  unavoid- 
able. They  are  not  unavoidable.  The  labor  of  children  10  to  14  years  of 
age  was  once  thought  unavoidable  and  was  condoned.  It  has  been  proved 
conclusively  that  such  labor  is  not  necessary.  So  long  as  children  are  allowed 
to  drift  about,  as  fancy  dictates,  from  job  to  job,  instability  and  unsatisfac- 
tory work  will  result.  Methods  should  be  worked  out  in  connection  with  the 
certification  of  children  for  work,  which  will  provide  that  a  child's  first  job 
is  selected  with  some  care  and  thought.  This  selection  should  be  determined 
by  the  inclination  of  the  child  as  much  as  possible,  but  also  by  his  physical 
and  mental  capacity,  ascertained  through  the  careful  medical  examination 
made. 

Unless  especially  pointed  out  in  the  description  of  the  particular  occupa- 
tion there  is  comparatively  little  health  hazard  for  a  normally  developed 
child,  16  years  of  age,  in  the  trades  where  he  is  found  employed  in  Cleveland, 
provided  the  legal  regulations  regarding  hours  and  conditions  of  work  are 


Health    and     Industry  597 

complied  with.  There  is  quite  a  definite  health  hazard,  however,  in  the 
effect  on  a  child  of  irregular  and  promiscuous  jobs,  or  in  work  uninteresting 
in  itself  and  holding  no  promise  of  a  real  vocation  in  the  future.  The  opinion 
of  the  director  of  boys'  employment  of  the  Public  Employment  Bureau 
in  Cleveland  is  of  weight  on  this  point.  After  several  years'  experience  she 
states  her  conclusions  as  follows:  "The  freshness,  interest  and  alertness  of 
the  boy  seeking  his  first  job  are  so  much  valued  by  employers  that  school 
boys  seeking  vacation  work  are  readily  hired,  even  though  their  services 
are  temporary.  Contrasting  strongly  with  the  keen  forcefulness  of  these 
school  boys  are  the  sullenness  and  stolid  disinterestedness  of  the  boys  who 
keep  changing  jobs.  Employers  have  corroborated  our  observations  that 
boys  are,  as  a  rule,  less  valuable  at  the  end  of  one  or  two  years'  work  than 
they  were  when  they  began  their  first  job.  The  chief  reason  for  this  unfor- 
tunate but  common  state  is  that  boys  leave  school  anxious  to  earn  money, 
and,  because  they  have  not  thought  about  a  trade  or  future  advancement, 
they  take  the  first  thing  they  happen  to  find.  This  is  usually  a  'blind- 
alley'  job  which  pays  from  the  start  a  reasonably  high  wage.  The  boy  is 
at  first  delighted  and  applies  himself  so  well  that  his  earnings,  if  on  a  piece- 
work basis,  become  higher.  If  he  wishes  to  speed  up  and  work  overtime, 
he  can  earn  more.  Because  of  his  high  weekly  earnings  at  this  rate,  if  he  has 
a  chance  on  another  job  at  a  higher  rate,  he  leaves  to  try  that.  After  a  year 
or  so  of  this,  the  results  noticed  in  him  are  definite  physical  deterioration, 
such  as  nervousness,  enervation,  drooped  shoulders,  sluggish  bodily  move- 
ments, and  slow  mental  reactions.  Boys  who  have  shown  great  promise 
when  their  applications  were  first  presented,  but  who  have  insisted  on  this 
kind  of  work,  have  been  a  real  disappointment  when  it  is  evident  what  their 
work  has  cost  them.  The  long,  confining  hours  of  industry,  unless  the  boy 
is  buoyed  up  by  the  stimulation  of  a  future  finished  apprenticeship  and  a 
worthy  goal  of  achievement,  and  the  loss  of  nervous  energy  in  high  speed 
jobs  stamp  upon  the  face,  figure  and  health  of  that  boy  the  price  he  has  had 
to  pay." 

It  is  largely  from  a  health  consideration  that  more  care  is  urged  in  the 
selection  of  jobs  for  children.  Children  have  a  right  to  work  and  in  many 
cases  the  effect  on  them  of  employment  is  highly  beneficial.  But  they  are 
not  adults  and  some  supervision  of  their  activities  in  industry  is  legitimate. 
Children  are  not  wholly  free  agents  in  the  selection  of  their  school  studies, 
and  there  is  no  reason  why  they  should  be  in  the  selection  of  work  until  they 
have  reached  the  age  of  maturity.  Boys  and  girls  of  16  have  not  reached 
the  age  of  maturity.  Left  to  their  own  direction  they  think  of  their  health 
last,  if  they  think  of  it  at  all.  If  they  are  directed  into  work  for  which  they 
are  physically  and  mentally  qualified,  the  health  hazard  involved  in  allowing 
young  children  to  work  daily  will  be  greatly  diminished. 


2.     Street  Trades 

There  is  no  provision  in  the  Ohio  State  Child  Labor  Law  relating  to 
newsboys,  and  other  street  traders.  There  is  a  Cleveland  city  ordinance, 
not  enforced,  containing  these  provisions: 


598  Hospital  and  Health  Survey 

No  boy  under  10  and  no  girl  under  18  years  of  age  may  work  at  all  on 
the  city  streets. 

I 

No  boy  under  14  years  of  age  may  work  on  the  city  streets  before  5:30 
in  the  morning  and  after  8  at  night. 

No  boy  10  years  of  age  and  over  may  work  on  the  city  streets,  without 
a  permit  issued  to  him  in  writing  by  the  mayor  of  Cleveland,  or  by  his  author- 
ized representative.  The  permit  shall  state  that  the  boy  is  mentally  and 
physically  fit  to  perform  this  work.  After  a  permit  is  secured  by  a  boy 
he  shall  receive  a  badge,  which  he  must  wear  while  at  work.  This  permit 
may  be  revoked  if  the  provisions  of  this  ordinance  are  violated.  Trades 
which  come  under  this  ordinance  are,  selling  of  papers,  periodicals,  gum, 
pencils,  candy,  perfume  and  other  commodities,  in  a  public  place. 

The  Consumers'  League  of  Ohio  has  campaigned  for  some  time  to  secure 
the  enforcement  of  this  ordinance.  Through  interviews  with  public  officials 
they  secured  the  following  promises: 

(a)  Mayor  Davis  said  that  he  would  authorize  someone  at  the  Board  of  Edu- 
cation to  issue  permits  and  badges. 

(b)  Superintendent  Spaulding  and  Mr.  Jones  have  promised  that  the  Board 
of  Education  would  issue  the  permits  and  badges,  provided  money  could 
be  raised  to  pay  for  the  latter. 

(c)  Chief  of  Police  Smith  has  promised  that  he  would  instruct  his  squad  in 
the  enforcement  of  this  ordinance.     Judge  Addams  will  cooperate. 

The  Consumers'  League  states  that  the  ordinance  is  not  now  enforced 
because — 

1.  The  newspapers  do  not  wish  regulation,  claiming  they  are  making  efforts 
to  take  care  of  the  trade  from  within. 

2.  There  is  no  money  in  the  city  license  department  to  pay  for  badges  (esti- 
mated cost  $300.) 

3.  There  is  no  money  to  pay  special  officers  to  be  detailed  to  this  particular 
work. 

Boys  and  a  few  girls  enter  these  trades  as  young  as  six  and  remain  in  them 
throughout  the  years  while  they  are  in  school.  The  majority  of  them  sell 
newspapers.  Anyone  who  will  take  the  trouble  to  observe,  may  judge  for 
himself  as  to  the  extent  that  newspapers  are  sold  on  the  downtown  streets 
and  busy  outlying  street  corners  by  small  boys. 

Nor  is  it  necessary  to  point  out  in  any  detail  the  undesirable  nature  of 
this  work  for  children.  Common  sense  alone  will  indicate  the  inadvisability 
of  allowing  children  from  six  years  of  age  up  to  spend  time  on  the  downtown 


Health     and     Industry  599 


streets,  in  an  atmosphere  of  great  confusion  and  excitement,  getting  home 
after  dark,  going  to  bed  late  and  having  irregular  and  badly  chosen  meals. 
The  fact  that  a  progressive  city  like  Cleveland  will  continue  to  allow  its  chil- 
dren to  hazard  their  health  and  safety  in  this  way  is  puzzling,  although  it 
may  be  an  illustration  of  the  extremes  to  which  American  sentiment  for 
business  independence  will  go.  There  is  a  very  real  appeal  made  by  the 
small  hustler  who  thrusts  an  evening  paper  at  the  passerby,  which  has  been 
felt  by  everyone,  but  it  requires  only  a  little  thought  to  realize  that  this 
appeal  is  not  justified  by  the  price  which  the  child  must  pay  in  the  end. 

For  the  purpose  of  securing  some  specific  information  as  to  the  extent 
and  general  character  of  the  newsboy  trade,  a  census  was  taken  in  a  downtown 
school  adjoining  the  business  district,  of  the  boys  in  that  school  who  were 
selling  newspapers  or  other  articles  on  the  streets.  There  are  about  800 
pupils  in  this  school,  400  of  whom  are  boys.  One  hundred  records  were 
secured  from  boys  and  10  from  girls  by  a  canvass  made  from  room  to  room. 
A  summary  of  these  records  is  found  in  Tables  XXIII.,  A  and  B,  in  the  Appen- 
dix. As  many  as  20  boys  under  10  years  of  age  were  found  who  sold  papers. 
Six  of  these  youngsters  sold  papers  until  after  8  at  night.  Fourteen  of  them 
earned  less  than  50  cents  a  day.  Twelve  of  them  were  classed  by  their 
teachers  as  not  having  good  health,  and  eleven  of  them  were  classed  as 
having  inferior  mental  capacity. 

According  to  the  ratings  of  age  and  grade  in  use  by  the  public  schools, 
59  of  the  100  boys  who  sold  papers  were  retarded  in  school  one,  two  and  three 
years.  Eight  additional  boys  were  in  a  special  "opportunity"  class  which 
was  not  graded.  17  out  of  the  100  boys  were  in  open  air  classes.  34  of  the 
100  boys  had  a  poor  health  record  and  16  a  fair  health  record,  making,  50% 
of  the  boys  whose  health  is  only  fair  or  poor.  All  of  the  boys  sold  papers  on 
Saturdays,  either  for  the  same  afternoon  and  evening  period  or  all  day. 

While  it  would  not  be  justifiable  to  conclude  that  the  physical  and  mental 
condition  of  these  boys  is  due  wholly  to  the  fact  that  they  sell  newspapers, 
as  there  are  probably  other'  contributing  factors,  such  as  home  conditions, 
ignorance  of  foreign-born  parents,  and  others,  the  fact  should  be  emphasized 
that  almost  two-thirds  of  these  boys  are  in  no  condition,  physically  or  men- 
tally to  justify  their  work  of  selling  papers  in  their  spare  time  after  school 
and  on  Saturdays. 

Seventeen  of  the  boys  were  found  in  open  air  classes.  This  means  that 
they  had  been  diagnosed  as  suffering  from  some  degree  of  poor  nutrition, 
and  so  were  placed  in  special  rooms  where  a  maximum  of  fresh  air  is  provided 
and  the  children  are  given  the  benefit  of  extra  food.  The  teachers  report 
that  the  children  improve  greatly  in  health  when  attending  these  open  air 
classes.  A  number  of  stories  of  the  newsboys  found  in  these  open  air  rooms 
are  of  interest. 

Arthur,  age  9,  in  the  third  grade,  sells  papers  every  afternoon  until  8 
o'clock  and  Saturday  the  same  time.  Saturday  morning  he  sells  boxes 
which  he  picks  up  around  the  market.     He  makes  about  50  cents  a  day. 


600  Hospital  and  Health  Survey 

He  is  only  a  fairly  good  student.     As  open  air  class  boys  rank,  his  health  is 
fair. 

Joe,  age  10,  in  the  fourth  grade,  delivers  papers  from  4:30  until  7  in  the 
morning.  He  sells  papers  after  school  until  6.  On  Saturday  his  hours  are 
from  4:30  a.  m.  to  7  a.  m.  and  from  9:30  a.  m.  to  6  p.  m.  He  makes 
about  75  cents  a  day.  Although  he  was  regular  in  attendance  at  school,  his 
physical  condition  is  poor.  He  was  a  failure  last  year  in  school,  and  at 
present  applies  himself  only  fairly  well. 

John,  age  11,  in  the  fifth  grade,  sells  papers  after  school  until  6.  He  is 
badly  undernourished,  and  is  only  a  fair  scholar.  He  expects  to  get  a  job 
and  work  this  summer. 

Peter,  age  11,  in  the  fifth  grade,  sells  papers  after  school  until  6  o'clock. 
He  makes  a  dollar  a  day.  He  has  been  selling  papers  for  a  year,  is  markedly 
nervous  and  jumpy.  He  has  been  a  truant  from  school  and  has  to  report  to 
the  truant  office.  He  is  bright,  but  he  is  not  able  to  apply  himself,  according 
to  his  teacher. 

Martin,  age  10,  in  the  fourth  grade,  works  after  school  until  6  o'clock, 
making  40  cents  a  day.  He  was  sick  and  lying  on  a  cot  when  interviewed. 
He  is  only  a  fair  student. 

Amelio,  age  11,  in  the  sixth  grade,  sells  papers  until  7  every  night  and 
on  Saturday  from  10  in  the  morning  until  8  at  night.  He  has  been  selling- 
papers  five  years.  He  is  regular  in  his  attendance  at  school,  but  not  very 
strong,  and  is  very  nervous.  His  health  has  improved  greatly  since  going 
into  the  fresh  air  class. 

Mike,  age  7,  in  the  second  grade,  sells  papers  until  7  at  night,  "making 
19  cents  a  day.  He  goes  to  the  office  with  his  brother  for  the  papers.  He  is 
frail  looking.     His  teacher  reports  that  he  is  not  at  all  well. 

Frank,  age  8,  in  the  third  grade,  sells  papers  from  7  in  the  morning  until 
school  time,  and  after  school  until  8.  He  makes  95  cents  a  day,  including 
tips.  His  health  seems  fair.  He  is  very  nervous,  talks  very  fast  and  stut- 
ters.    He  is  in  a  special  class  for  stutterers,  and  tries  very  hard  to  overcome  it. 

Billy,  age  8,  in  the  second  grade,  sells  papers  until  10  at  night.  It 
takes  him  a  half  hour  to  get  home  from  the  downtown  district  where  he 
works.  The  school  nurse  and  doctor  cannot  find  anything  wrong  with  him, 
but  they  have  not  been  able  to  understand  his  sleepiness.  The  teacher 
states  that  it  has  been  a  struggle  all  the  year  to  keep  him  going.  "He  is  so 
lifeless,  bright  enough  and  gets  along  well  enough  in  his  studies,  but  has  no 
energy." 

Sam,  age  11,  in  the  fifth  grade,  delivers  papers  from  5  to  7:30  in  the  morn- 
ing and  sells  after  school  until  6.     He  makes  a  dollar  a  day.     He  has  been 


Health     and     Industry  601 

selling  papers  two  years.  He  is  small,  nervous  and  of  a  high  strung  type. 
He  is  bright,  a  good  student,  and  has  been  a  truant,  but  not  at  the  present 
time. 

Joe,  age  11,  in  the  fifth  grade,  sells  papers  until  7  o  'clock.     Then  every 
night  and  Sunday  he  watches  tickets  in  a  show  until  9  o'clock.     He  gets  75 
.cents  a  week  for  this.     He  is  undersized  and  not  strong.     He  is  intelligent 
and  a  good  student. 

Joe,  age  12,  in  the  fifth  grade,  sells  papers  after  school  until  7,  making 
40  cents.  He  has  been  selling  papers  for  five  years.  On  Saturday,  from  8 
in  the  morning  until  4  in  the  afternoon,  he  sells  boxes  which  he  picks  up 
around  the  market,  making  about  $1.50.  On  Sunday  he  shines  shoes  from 
8  to  10  in  the  morning,  making  50  cents.  He  gives  the  money  to  his  mother. 
She  usually  gives  him  a  dime.  He  is  very  anaemic  and  not  in  good  health. 
His  scholarship  record  is  poor.  He  does  not  apply  himself,  and  his  teacher 
considers  that  he  has  dull  mentality. 

These  cases,  selected  at  random,  show  very  clearly  the  kind  of  life  which 
newsboys  lead.  While  the  amount  of  money  they  make  varies  in  many 
cases,  it  is  not  worth  the  time  spent  making  it.  It  should  be  noted  that  in 
every  case  where  boys  are  working  later  than  6  o'clock  their  physical  condi- 
tion shows  the  effect  of  their  late  hours  and  irregular  meals. 

Their  hours  out  of  school  should  be  occupied  in  a  manner  which  will  not 
drain  their  vitality  further.  The  excitement  of  street  life  with  its  over 
stimulation  of  young  nerves  and  energies  requires  sound  health  and  strength 
to  withstand  its  strain.  Boys  should  not  be  allowed  to  engage  in  newspaper 
selling  and  other  street  trading  unless  they  can  show  a  clean  bill  of  health 
and  are  up  in  their  school  studies.  Boys  like  and  enjoy  this  kind  of  work, 
in  most  cases.  If  they  are  allowed  to  engage  in  it  only  when  they  can  com- 
ply with  a  certain  standard  of  scholarship  and  physical  ability,  the  desire  to 
become  a  newsboy  could  be  utilized  as  the  necessary  incentive  to  master 
school  studies  and  develop  health  habits. 

It  is  recommended  that  the  city  ordinance  regulating  street  trades  be 
enforced,  pending  amendment  of  the  ordinance  or  inclusion  of  these  trades 
in  the  state  law.  Permits  to  boys  to  engage  in  this  work  and  badges  to  be 
worn  by  them  while  at  work,  should  be  issued  through  the  work  certificate 
office  of  the  Board  of  Education,  where  each  boy  will  receive  a  medical  ex- 
amination showing  him  to  be  physically  fit  for  this  occupation  before  he  can 
obtain  a  permit. 

Early  morning  paper  delivery  should  also  be  regulated  by  issuance  of 
certificates  based  on  physical  fitness  for  this  work. 

Although  regulation  of  this  trade  does  not  come  under  the  state  school 
law,  the  enforcement  of  the  existing  city  ordinance  directly  affects  pupils 
throughout  their  school  life  and  unless  some  effort  is  made  tojteep  watch  of 


602  Hospital  and  Health  Survey 

the  children  in  these  trades,  their  unguarded  pursuit  of  them  will  break  down 
the  work  of  the  Board  of  Education  in  the  medical  and  truancy  departments. 

It  is  logical  that  children  in  the  school  system  engaging  in  these  trades 
should  do  so  only  under  the  direction  of  the  Board  of  Education,  so  that  the 
wTork  of  the  medical  and  truancy  departments  may  not  be  nullified  by  the 
extra-school  activities  of  these  children. 


3.     Agricultural  Work  and  Domestic  Service 

Neither  of  these  groups  of  work  is  included  in  the  list  of  occupations 
employing  children  wrhich  come  under  the  regulation  of  the  State  Child  Labor 
Law7.  The  number  of  children  wrho  are  employed  at  these  kinds  of  work 
cannot  even  be  guessed  at,  as  no  record  is  kept  of  them  in  any  place.  Un- 
doubtedly some  of  the  6,778  girls  16  to  18  years  of  age,  listed  by  the  school 
census  as  working,  are  employed  in  domestic  service. 

Agricultural  work  for  children  under  18  does  not  affect  any  number  of 
children  in  Cleveland  except  in  one  situation,  wrhich  is,  how7ever,  of  consider- 
able importance.  This  is  the  case  of  children  who  leave  Cleveland  in  the 
early  spring  and  remain  until  the  late  fall  to  work  in  agricultural  fields  either 
in  Ohio  or  elsewhere.  The  children  are  recruited  by  agents  who  are  paid  by 
the  farmer  who  employs  them  so  much  a  head  for  children  recruited.  These 
agents  obtain  individual  children  without  their  parents,  or  whole  families, 
and  transport  them  to  the  locality  wrhere  they  are  to  wrork. 

Principals  of  schools  in  districts  where  there  is  an  industrial  population 
report  that  every  spring  about  six  weeks  or  two  months  before  the  close  of 
school,  or  in  April  sometimes,  there  is  an  exodus  of  children  and  families 
from  the  district.  One  school  principal  reported  that  20  families  and  some 
boys  had  gone  from  her  district,  taking  about  100  children  altogether,  the 
majority  of  w7hom  were  her  school  pupils.  They  went  to  work  in  the  beet 
fields  near  Flint,  Michigan,  and  were  signed  up  by  agents  who  came  into  the 
district  and  went  directly  to  the  homes  of  the  families.  In  this  school  dis- 
trict there  are  Italians,  Slavs  and  Hungarian  gypsies.  The  Italians  do  not 
undertake  this  kind  of  work,  but  many  Slavs  and  most  of  the  Hungarian 
gypsies  go. 

This  happens  every  spring.  These  people  will  return  about  one  month 
after  school  begins.  The  children  miss  from  two  to  three  months  of  school 
and  considerable  retardation  in  school  is  the  result. 

All  of  the  children  from  6  years  of  age  upward  work  in  the  beet  fields. 
According  to  the  statement  of  this  school  principal  even  the  little  tots  bring 
home  as  much  as  $150.00  for  the  season's  work.  The  living  conditions  are 
primitive.  The  people  live  in  shacks  and  very  bad  sanitary  conditions  pre- 
vail. The  National  Child  Labor  Committee  has  made  considerable  research 
into  this  form  of  work  and  has  found  very  undesirable  situations  in  every 
state  visited. 


Health    and    Industry  603 

So  far  as  is  known  practically  no  boys  are  employed  in  domestic  service. 
As  before  stated,  it  is  impossible  to  make  any  estimate  of  the  number  of 
girls  under  18  years  of  age  so  employed.  In  the  canvass  made  of  one  school 
to  obtain  information  as  to  the  numbers  of  children  working  after  school 
hours  at  selling  papers,  it  was  learned  incidentally  that  quite  a  number  of 
girls  14  years  of  age  and  under  were  doing  housework  after  school  and  on 
Saturdays. 

Experts  in  industrial  diseases  state  that  housework  contains  more  health 
hazards  than  are  found  in  any  other  industry.  There  are  no  statistics  avail- 
able to  sustain  this  statement,  but  it  would  be  wise  to  make  a  study  of  this 
occupation  and  accumulate  more  accurate  information  regarding  it.  It  is 
questionable  whether  housework  has  any  beneficial  effects  on  the  health  of 
very  young  girls  who  engage  in  it. 

Both  of  these  occupations  should  have  age  limitations  and  some  super- 
vision of  conditions  of  work,  particularly  agricultural  work.  There  should 
be  an  age  limit  of  at  least  12  for  these  occupations  and  a  limitation  of  the 
hours  of  work,  similar  to  the  limitations  in  hours  for  other  occupations.  A 
health  certificate  should  be  required  of  every  child.  Regulation  of  condi- 
tions of  work  may  involve  some  difficulties  needing  the  cooperation  of  other 
agencies,  but  examinations  for  a  health  certificate  can  be  conducted  in 
the  same  manner  as  for  other  occupations  by  the  existing  machinery,  with- 
out great  difficulty.  By  limiting  the  age  and  the  hours  of  work  of  children 
engaging  in  these  occupations  and  by  requiring  of  them  a  certificate  of 
physical  fitness  for  this  kind  of  work,  their  health  will  be  better  safeguarded. 


HEALTH  OF  CHILDREN  AT  WORK 

1.     Medical  Examination  of  Children  for  Work  Permits 

"Little  has  been  done  up  to  the  present  time  in  the  United  States  to  pre- 
vent children  from  going  into  work  for  which  they  are  physically  unfit,  and 
practically  no  study  has  been  made  of  the  effects  of  early  labor  on  the  growth 
of  the  body.  Many  children  who  begin  work  between  the  ages  of  14  and  18 
are  the  children  of  least  resistance  in  the  community.  They  are  in  general 
the  children  of  the  poor,  and  in  consequence  are  likely  to  be  the  ill-nourished, 
the  undersized  and  the  anaemic.  Already  handicapped,  their  growing  bodies 
can  offer  no  resistance  to  the  exacting  demands  of  industry  on  muscles  and 
nerves.  During  these  maturing  years  they  are  peculiarly  liable  to  injury 
from  overstrain  and  peculiarly  sensitive  to  all  sorts  of  industrial  hazards. 

"A  great  deal  of  the  work  done  by  children  is,  moreover,  totally  unfit  for 
them.  It  often  involves  too  much  sitting,  or  too  much  standing,  the  carrying 
of  weights  beyond  the  child's  strength,  the  over  exercising  of  one  set  of 
muscles  at  the  expense  of  another,  and,  in  certain  occupations,  the  loss  of 
sleep.  Foreign  investigations  have  shown  that  the  sickness  rate  among 
juvenile  laborers  is  alarming,  especially  during  the  second  year  of  working  life 
when  the  injurious  effects  of  early  labor  upon  already  undeveloped  bodies 
have  had  time  to  make  themselves  felt. 


604  Hospital  and  Health  Survey 


^'A  'physical  minimum'  for  children  entering  employment  was  provided 
in  the  standards  adopted  by  the  Children's  Bureau  Conferences  held  in 
Washington  and  other  large  cities  in  May  and  June,  1919.  This  minimum 
proposed  that  'A  child  shall  not  be  allowed  to  go  to  work  until  he  has  had  a 
physical  examination  by  a  public  school  physician  or  other  medical  officer 
especially  appointed  for  that  purpose  by  the  agency  charged  with  the  enforce- 
ment of  the  Jaw,  and  has  been  found  to  be  of  normal  development  for  a  child 
of  his  age  and  physically  fit  for  the  work  at  which  he  is  to  be  employed.' 
It  proposed  also  that  'There  shall  be  an  annual  physical  examination  of  all 
working  children  who  are  under  18  years  of  age.'  (For  the  complete  text  of 
the  standards,  see  pages  3,  4,  5  of  Conferences  Series  2,  Bureau  Publication 
No.  62  of  Children's  Bureau  of  the  U.  S.  Dept.  of  Labor.) 

"But  what  constitutes  'normal  development'  for  boys  and  girls  of  dif- 
ferent ages,  and  what  indicates  that  a  child  is  'physically  fit'  for  the  employ- 
ment which  he  is  about  to  enter?  Only  through  exact  observation  and  meas- 
urements can  it  be  demonstrated  that  a  child  is  unfit  for  certain  kinds  of 
work,  or  that  too  early  and  too  exacting  labor  is  endangering  his  physical 
development.  The  standards  to  be  applied  constitute  a  vitally  important 
part  of  the  problem  of  child  labor." 

The  above  paragraphs  are  quoted  from  the  statement  of  the  Federal 
Children's  Bureau  made  at  the  time  of  the  appointment  of  its  Committee 
on  Health  Standards  for  Children  Entering  Industry.  It  states  very  clearly 
the  necessity  for  special  care  for  children  of  these  years  who  are  going  to 
work. 

In  the  descriptions  of  the  various  occupations  in  which  children  were 
found  employed  in  Cleveland  an  effort  has  been  made  to  point  out  the  par- 
ticular health  hazard,  if  any,  present  in  each.  There  is,  however,  some  health 
hazard  in  any  kind  of  employment  for  growing  boys  and  girls,  unless  their 
work  is  carefully  supervised.  Their  physical  and  nervous  organisms  are  not 
yet  stabilized.  They  have  less  endurance,  and  they  are  more  susceptible  to 
fatigue  and  bodily  strain.  Postural  strain  is  most  likely  to  be  overlooked 
unless  a  child  receives  some  medical  supervision  after  his  initial  examination 
for  a  certificate.  The  bony  structure  of  a  child  is  quite  flexible.  Children 
are  peculiarly  susceptible  to  deformities  if  subjected  to  unusual  and  pro- 
longed strain  on  one  set  of  muscles,  the  use  of  which  is  especially  required 
by  the  job  at  which  they  are  employed. 

In  the  future,  probably  industry  itself  will  exercise  more  supervision  over 
the  work  engaged  in  by  children  in  its  employ.  The  attitude  of  many  em- 
ployers at  the  present  time  is  exceedingly  intelligent  and  considerate,  in  so  far 
as  they  have  knowledge  of  the  physical  needs  of  children  15  to  18  years  old. 
As  the  medical  service  in  industrial  plants  develops  there  will  be  better 
facilities  for  close  observation  of  children  at  work,  and  of  the  effect  on  them 
of  different  kinds  of  work.  It  will  be  possible  to  make  finer  adjustments 
between  children  and  the  tasks  they  perform  which  will  definitely  affect 
their  health  and  efficiency. 


Health     and     Industry  605 

Pending  the  time  when  industrial  medical  service  can  share  this  respon- 
sibility, the  health  of  children  in  industry  must  be  guarded  by  the  public 
department  which  has  the  responsibility  of  examining  the  mental  and  physi- 
cal abilities  of  children  applying  for  working  certificates. 

In  Cleveland  this  work  is  done  in  connection  with  the  Department  of 
Medical  Inspection  in  Schools  of  the  Board  of  Education.  The  present 
requirement  in  the  Ohio  School  Law  of  a  health  certificate  for  every  child  going 
to  work  has  been  only  superficially  observed  until  the  past  year.  The  present 
director  of  the  work  has  been  at  work  since  last  June.  Records  have  been 
in  use  only  since  September,  1919.  Therefore,  there  are  no  data  available  for 
a  longer  period  than  one  school  year. 

Children  are  examined  carefully  as  to  eyesight,  hearing,  teeth,  throat, 
lungs  and  heart,  and  are  looked  over  for  bodily  defects,  fallen  arches,  evidences 
of  malnutrition.  All  children  are  measured  and  weighed.  They  are 
questioned  on  their  previous  health  history  and  for  any  diseases  from 
which  they  have  suffered,  such  as  epilepsy,  rheumatism,  contagious  diseases, 
influenza,  etc.  This  is  quite  a  casual  inquiry  of  the  whole  group  being  ex- 
amined. On  the  occasion  when  the  procedure  was  observed  15  girls  were 
being  examined,  and  as  the  room  is  small  there  was  some  confusion.  The 
girls  took  a  personal  interest  in  each  individual  examined,  crowding  around 
her  until  ordered  back.  f- 

The  information  obtained  is  recorded  on  each  child's  health  record  and 
filed.  Separate  files  are  arranged  for  records  of  children  with  serious  physical 
defects,  of  children  requiring  correction  of  defects,  and  of  children  who  are  to 
be  re-examined  at  a  later  period.  The  last  named  usually  have  conditional 
certificates.  The  medical  officer  spends  about  three  hours  daily  in  the  office 
and  a  daily  report  is  made  up  which  is  kept  in  the  school  medical  inspection 
office.  These  records  show  the  total  number  of  boys  and  girls  examined, 
the  number  considered  defective  and  those  who  were  relatively  sound,  the 
different  defects  found  and  the  number  of  corrections  effected  during  the  8' 
months  from  September  to  May. 

In  the  8  months  from  September,  1919  to  May,  1920,  there  were  examined 
2,348  children,  1,001  boys  and  1,347  girls!  492  of  the  boys  and  19  of  the 
girls,  or  1,111  of  the  children,  had  one  or  more  physical  defects.  The.  com- 
plete figures  from  these  records  will  be  found  in  Tables  XXIV.  and  XXV.: 
in  the  Appendix. 

The  defects  from  which  children  were  suffering  in  largest  numbers  were 
carious  teeth,  defective  vision  and  poor  nutrition.  623  children  had  defec- 
tive teeth,  of  which  number  367  were  later  reported  corrected.  199  children' 
were  handicapped  by  defective  vision,  of  which  number  109  were  later  re-r 
ported  as  having  corrections  made.  403  children  were  suffering  from  sorrie 
degree  of  poor  nutrition.  There  was  no  record  of  treatment  recommended1 
or  received  in  these  cases.  27  children  were  diagnosed  as  suspicious  or1 
positive  tubercular  cases.  '■'■ 


606  Hospital  and  Health  Survey 

The  records  of  the  large  number  of  children  suffering  from  decayed  teeth, 
in  many  cases  so  bad  that  repair  was  impossible,  from  defective  vision  and 
from  poor  nutrition,  indicate  that  the  work  of  school  medical  inspection  is 
not  adequate.  Children  should  not  be  allowed  to  reach  the  ages  of  15  and 
16  with  such  uncared-for  teeth  that  many  must  be  extracted.  Poor  nutri- 
tion may  be  due  to  a  number  of  causes.  More  study  of  the  subject  of  nutri- 
tion is  necessary.  The  school  medical  department  is  already  conducting 
experiments  and  classes  in  nutrition  which  it  is  hoped  will  lead  to  the  diminu- 
tion of  the  undernourishment  which  handicaps  so  many  school  children.  In 
some  cities  a  minimum  standard  of  nutrition  is  set,  determined  according  to 
the  height,  weight  and  age  of  the  child,  as  requisite  for  a  health  certificate. 

It  is  not  within  the  functions  of  this  department  to  do  other  than  examine 
children  and  prescribe  treatment  for  physical  defects  discovered.  No  medical 
or  dental  work  is  done.  The  child  is  sent  back  to  his  own  physician  for  treat- 
ment. In  case  it  is  understood  that  the  parents  of  the  child  are  unable  to 
pay  for  such  care,  the  child  is  referred  to  one  of  the  public  dispensaries. 

In  order  to  obtain  prompt  action  on  the  part  of  parents  in  having  the 
prescribed  corrections  made,  certificates  are  usually  refused  until  the  work 
has  been  done  or  until  the  child  can  show  evidence  that  the  corrections  are 
under  way.  A  conditional  certificate  valid  for  a  short  period  of  time  is  often 
given  to  a  child  who  is  under  medical  or  dental  treatment  for  some  remediable 
defect.  At  the  end  of  the  period  for  which  the  conditional  certificate  has 
been  given  the  child  must  return  to  the  office  and  show  evidence  that  the 
defect  has  been  corrected  before  he  can  obtain  a  permanent  certificate. 

While  this  department  has  been  organized  less  than  a  year,  it  is  already 
fairly  well  established,  and  its  work  is  proving  its  value.  The  officers  are 
much  interested  in  its  development  and  the  outlook  is  promising  for  an 
organization  having  a  splendid  influence  on  the  health  problems  of 
children  going  to  work.  The  department  needs  to  be  considerably  expanded 
and  its  working  force  increased.  Health  standards  for  children  going  into 
industry  should  be  formulated,  patterned  after  those  soon  to  be  issued  by 
the  Federal  Children's  Bureau  Committee  already  mentioned.  A  summary 
of  the  committee's  preliminary  report  on  standards  is  included  at  the  end  of 
this  section.  One  of  the  functions  of  the  department  still  to  be  developed 
should  be  sufficient  contact  with  the  industrial  field  to  assure  familiarity 
with  the  jobs  in  which  children  are  employed,  in  order  that  the  examining 
physicians  may  be  able  to  decide  intelligently  as  to  the  desirability  of  dif- 
ferent kinds  of  work  for  the  various  children  examined. 

It  is  to  be  regretted  that  there  are  no  health  records  available  for  a  longer 
period  of  time  than  one  year.  It  is  not  possible  to  learn  from  the  records  of 
one  year  only,  the  physical  effects  of  employment  on  children,  data  which  it 
is  important  to  collect  before  conclusive  statements  can  be  made  as  to  the 
desirability  of  this  or  that  occupation  for  children.  A  prominent  activity  of 
this  department  should  be  the  study  of  the  various  occupations  which  chil- 
dren enter,  and  the  accumulation  of  evidence  of  the  development  of  children 
after  a  period  of  months  and  years  in  these  occupations.     This  information 


Health     and     Industry  607 

can  only  be  obtained  by  means  of  periodic  medical  examinations  of  children 
after  employment  has  begun.  The  Ohio  law  relating  to  health  certificates 
for  work  permits  should  be  amended  to  require  such  periodic  medical  exami- 
nations. The  law  should  be  amended  also  to  assure  a  medical  examination 
in  every  case  before  a  certificate  is  issued  for  a  specific  job.  The  pledge  of 
the  employer  required  in  the  present  law  should  be  amended  to  specify  the 
exact  nature  of  the  work  a  child  is  to  do,  as  otherwise  a  child  may  be  trans- 
ferred to  work,  other  than  that  for  which  he  received  his  work  certificate, 
which  may  be  injurious  to  his  health.  The  amendments  to  the  present  law 
can  be  made  as  in  the  suggested  form  of  the  law,  which  follows: 


2.     Suggested  Content  of  Ohio  Law  re  Health  Certificate  for 
Child  Applying  for  a  Work  Certificate. 

Section  7764-1  (4)  Health  Certificate.  A  certificate  from  the  school 
physician,  or  if  there  be  none,  from  the  board  of  health,  and  if  there  be  no 
board  of  health  within  the  school  district  in  question,  from  a  licensed  physi- 
cian appointed  by  the  board  of  education,  showing  after  a  thorough  medical 
examination  that  the  child  is  physically  fit  to  be  employed  at  the  specific 
occupation  for  which  the  child  makes  application  for  a  permit,  such  occupation 
to  be  one  not  prohibited  by  law  for  a  child  under  18  years  of  age. 

Periodical  examination  of  children  who  have  been  granted  one  health 
certificate  shall  be  provided  for  by  limiting  the  period  of  time  for  which 
certificates  may  be  issued  to  two  periods  of  six  months  each  and  one  period 
of  one  year  successively.  A  thorough  medical  examination  showing  the 
child  to  be  physically  fit  for  the  employment  in  which  he  is  to  engage  or  is 
engaged  shall  be  necessary  in  every  case,  before  a  certificate  may  be  issued. 
Certificates  may  be  granted  for  shorter  periods  of  time  than  six  months  or 
one  year,  successively,  if  the  physical  condition  of  the  child  warrants  more 
frequent  examination,  or  if  the  child  is  allowed  to  work  while  receiving  medi- 
cal treatment  for  correction  of  remediable  physical  defects. 

A  new  certificate  shall  be  required  upon  every  change  of  employment. 

An  adequate  force  of  qualified  physicians  and  others  shall  be  provided 
for  the  work  of  examination  and  follow-up  which  may  be  necessary. 

(Pledge  of  Employer)  (1)  A  pledge  or  promise  signed  by  the  employer 
or  by  an  authorized  manager  or  superintendent,  specifying  the  exact  nature 
of  the  work  which  the  child  is  required  or  permitted  to  do,  the  number  of 
hours  per  day  during  which  the  child  is  to  be  regularly  employed,  and  the 
name  and  address  of  the  employer,  in  which  pledge  or  promise  the  employer 
agrees  to  employ  the  child  in  accordance  with  the  provisions  of  this  act,  and 
to  return  to  the  superintendent  of  schools  or  to  the  person  authorized  by 
him  to  issue  such  certificates,  the  age,  schooling  and  health  certificate  of  the 
child  within  two  days  from  the  date  of  the  child's  withdrawal  or  dismissal 
from  the  employer,  giving  the  reasons  for  such  withdrawal  or  dismissal. 


608  Hospital  and  Health  Survey 


3.     Subnormal  Children  in  Industry 

There  are  at  present  no  means  of  ascertaining  the  mental  capacities  of  all 
children  wishing  to  go  to  work,  other  than  the  school  record,  which  is  too 
brief  to  furnish  any  information  except  the  fact  that  the  child  has  completed 
a  specific  school  grade.  Completion  of  the  sixth  grade  is  required  of  all  boys 
and  of  the  seventh  grade  of  all  girls.  If  it  is  decided  that  the  mental  capacity 
of  a  child  is  such  that  he  cannot  pass  the  required  grade,  that  child  may  obtain 
a  special  permit  to  go  to  work,  other  requirements  being  complied  with. 
School  children  who  are  suspected  of  being  mentally  deficient  are  tested  by 
the  examiner  of  subnormal  children  of  the  Department  of  Medical  Inspection 
of  the  Board  of  Education.  Only  a  small  number  of  the  subnormal  children 
in  the  city  are  so  examined.  Such  of  those  known  deficient  children  as  apply 
at  the  attendance  department  for  a  certificate  to  work,  have  on  their  school 
record  the  fact  of  their  deficiency,  and  that  fact  is  taken  into  consideration 
when  the  children  are  medically  examined  for  a  certificate.  This  information 
is  invaluable  in  directing  a  child  into  the  sort  of  work  for  which  he  is  most 
suited  because  of  his  mental  disability.  A  15  year  old  boy  went  into  the 
attendance  department  one  day  to  obtain  a  permit  to  drive  a  truck  for  a 
construction  company.  He  proved  to  be  physically  sound  and  during  the 
time  while  he  was  being  examined  seemed  normal.  His  school  record  showed 
that  he  was  mentally  deficient,  having  tested  to  a  mental  age  of  eight.  The 
doctor  promptly  refused  to  grant  him  a  permit  for  that  job,  as  it  did  not 
seem  wise  to  allow  a  boy  of  eight  year  old  mentality  to  drive  a  truck  about 
the  city  streets. 

There  has  been  some  discussion  in  the  department  as  to  the  advisability 
of  putting  the  statement  of  a  child's  mental  deficiency  on  his  school  record, 
which  goes  to  the  work  certificate  office.  Some  officials  felt  that  it  was 
unfair  to  handicap  the  child  in  this  way  in  finding  employment.  It  is  true 
that  such  a  statement  may  not  give  a  fair  representation  of  the  child's  ca- 
pacity. The  circumstances  under  which  mental  tests  are  given  to  a  child 
may  be  such  as  to  upset  a  not  too  well  balanced  mentality;  that  is,  to  a 
child  in  any  degree  uncertain  of  himself,  it  would  be  very  upsetting  to  have  to 
answer  questions  by  strange  people  in  the  presence  of  his  teacher  and  others 
who  are  strangers  or  of  whom  he  is  afraid.  In  such  cases  no  child  would 
give  a  very  good  account  of  his  faculties.  Furthermore,  intelligence  tests  are 
still  in  the  field  of  research,  and  not  yet  completely  developed.  It  should 
not  be  so  difficult  to  ascertain  the  mental  capacity  of  an  adult  whose 
faculties  have  become  somewhat  crystallized,  but  it  is  questionable  whether 
one  group  of  tests  as  now  used  can  set  a  value  on  the  faculties  of  a  growing 
child  some  of  whose  abilities  are  still  latent.  One  employer,  who  has  con- 
siderable sympathy  for  handicapped  children,  stated  'that  he  took  three 
certificate  boys  who  were  mentally  subnormal  and  put  them  to  work  in  the 
machine  shop.  That  was  a  year  or  so  ago.  Two  of  the  boys  were  still  there 
this  spring,  and  one  of  them,  his  employer  states,  is  making  one  of  the  best 
machinists  in  the  shop  and  is  an  assistant  foreman.  It  was  his  opinion  that 
the  tests  which  classed  these  boys  as  subnormal  were  too  narrow  in  their 
scope,  giving  no  indication  of  the  fact  that  their  ability  might  be  entirely 
along  ;i  mechanical  line. 


Health     and     Industry  609 

Whatever  the  facts  may  be  as  to  the  adequacy  of  the  tests  as  now  given, 
their  usefulness  is  undeniable  and  those  in  charge  of  them  are  exerting  earnest 
effort  to  make  the  tests  used  complete,  reliable  and  in  step  with  the  latest 
findings  in  this  field  of  research.  While  more  efficient  tests  may  be  worked 
out,  those  already  in  use  are  of  great  assistance  in  indicating,  even  if  crudely, 
differences  in  mental  capacities. 

Any  knowledge  of  a  deficiency  in  mentality  of  a  child  wishing  to  go  to 
work  should  be  communicated  to  his  employer,  as  a  protection  both  to  the 
child  and  to  the  employer.  In  the  visits  to  industrial  establishments  made 
during  the  course  of  this  study,  employers  were  questioned  as  to  this  point 
and  the  answer  was  invariably  the  same.  "This  information  should  be  on 
the  certificate  of  the  child.  It  is  of  great  assistance  to  us  in  deciding  just 
Avhat  the  child  shall  do,  and  it  protects  us  both  from  the  chance  of  an  accident." 

A  study  was  made  of  all  the  records  of  the  subnormal  children  applying 
at  the  work  certificate  office  for  working  papers  from  September,  1919,  to 
March,  1920.  Of  the  2,323  health  records  on  file  in  the  office  for  that  period 
148  were  those  of  children  whose  mentality  was  deficient.  According  to 
these  records  6.4%  of  all  children  having  work  permits  are  subnormal. 
This  does  not  represent  the  total  number.  It  represents  only  those 
children  whose  subnormality  had  been  ascertained  while  they  were  in 
school.  In  close  connection  with  the  medical  examination  for  work  certifi- 
cates there  should  be  facilities  for  determining  more  accurately  the  mental 
capacities  of  all  children  wishing  to  go  to  work.  The  data  available  from 
such  examinations  will  be  an  exceedingly  valuable  contribution  to  the  studies 
of  employment  for  children  which  are  now  being  made. 

A  careful  study  was  made  of  the  148  records  of  children  of  subnormal 
mentality.  The  work  which  these  children  were  doing  was  analyzed,  their 
physical  defects  tabulated  and  mental  age  recorded.  In  Table  XXVI.  in 
the  Appendix  the  information  thus  obtained  is  shown  in  detail. 

There  was  more  deficiency  among  the  boys  than  among  the  girls,  as  the 
subnormal  boys  were  8.6%  of  the  total  number  of  boys  who  had  obtained 
work  certificates  and  the  subnormal  girls  were  4.8%  of  the  total  number  of  girls. 

Twenty-seven  of  the  boys  and  twenty-two  of  the  girls  had  no  physical 
defects.  Poor  nutrition  and  bad  teeth  were  the  chief  sources  of  trouble  for 
both  boys  and  girls.  In  many  cases  the  two  went  together.  While  the 
number  of  cases  of  defective  vision  was  not  great,  it  should  be  noted  that 
what  is  described  as  mental  deficiency  in  children  is  not  infrequently  retarded 
mental  development  due  to  bad  vision.  13  girls  and  8  boys  who  had  tested 
subnormal  in  school  came  to  the  work  certificate  office  with  defects  in  eye- 
sight which  should  have  been  corrected  before,  in  view  of  the  fact  that  the 
children  were  thought  to  be  defective  and  had  proved  to  be  so  upon  being 
tested. 

Not  all  of  the  children  who  had  applied  for  work  certificates  were  at  work. 
Between  a  third  and  a  half  of  the  certificates  had  been  returned  to  the  office, 


<>1()  Hospital  and  Health  Survey 

showing  that  the  children  had  left  their  original  jobs.  As  the  office  has  not 
followed  up  such  cases,  it  is  not  known  wThether  these  children  got  other  jobs 
and  are  working  illegally  or  whether  they  are  staying  out  of  school  at  home. 

The  jobs  for  which  the  children  had  certificates  could  be  classified  in 
three  general  groups,  machine  work,  hand  work  and  errand  work.  Almost 
half  of  the  boys  were  doing  errand  work  as  messengers,  wagon  boys,  etc. 
The  machine  work  was  of  a  simple  sort,  such  as  is  done  in  a  large  knitting 
mill.  Under  hand  work  was  grouped  a  large  number  of  jobs  in  sorting  and 
packing  products,  all  of  which  require  practically  no  skill  and  involve  the 
repetition  many  times  of  one  simple  operation.  Employers  seem  to  have 
no  objection  to  this  group  of  workers.  In  many  cases  the  work  is  very  little 
different  from  that  required  of  normal  children.  As  before  stated,  the  kind 
of  work  which  many  young  children  are  doing  is  exceedingly  simple,  is  easily 
learned  and  involves  little  or  no  mental  effort. 

A  question  which  requires  study  and  which  must  be  settled  regarding 
such  children,  is  whether  or  not  they  should  continue  in  special  schools  where 
they  can  receive  more  training,  or  whether  they  should  be  more  carefully 
inducted  into  industry  where  they  can  be  under  the  stabilizing  influence  of 
regular  work. 

Opinion  differs  on  this  point.  Some  teachers  of  backward  children  regret 
very  much  that  they  leave  before  16  years  of  age,  saying  that  it  takes  several 
years  of  special  work  to  get  any  results  with  the  children.  Others  believe 
that  they  are  better  off  at  work  than  in  school  and  that  the  law  requiring 
their  attendance  in  school  should  be  more  flexible  than  it  is,  in  order  that 
such  individuals  may  get  to  work  as  soon  as  possible.  Such  children  can  re- 
ceive their  industrial  training  to  better  advantage  in  a  shop  than  they  can 
in  a  special  class  in  school,  where  only  meagre  industrial  equipment  is  pos- 
sible. 

In  Cincinnati  a  special  committee  supervises  the  industrial  careres  of  all 
such  children.  In  Baltimore  unusual  boys  are  taken  from  school  and  put 
to  work  under  the  direction  of  a  department  having  this  special  responsi- 
bility. The  effect  of  carefully  directed  work  on  the  character  development 
of  these  boys  has  been  noteworthy.  An  experiment  of  this  kind  is  well 
worth  trying.  Too  little  is  known  of  the  possibilities  which  lie  in  the  right 
kind  of  work  for  backward  and  unusual  children.  It  is  suggested  that  a 
special  arrangement  should  be  made  in  the  work  certificate  offices  whereby 
children  of  this  group  will  be  carefully  studied  and  directed  into  employment 
and  followed  up  after  they  are  at  work. 


i.     Summary  of  Standards  of  Normal  Development  and  Physical 
Fitness  for  Working  Children 

(Tentative  report  of  the  committee  appointed  by  the  U.  S.  Children's 
Bureau  to  formulate  standards  for  the  use  of  physicians  in  examining  chil- 
dren entering  employment  and  children  at  work.) 


Health     and     Industry  ■  611 

A.     GENERAL  RECOMMENDATIONS 

1.  Age  Minimum  for  Entrance  into  Industry. 

Should  be  not  less  than  16  years.  It  is"  important  to  protect  a  child  from  the  physical 
and  nervous  strains  of  industry  because  of  his  general  instability  during  the  pubescent 
period. 

2.  Physical  Minimum  for  Entrance  into  Industry. 

No  child  under  18  years  should  be  permitted  to  go  to  work  who  is  not  normally  de- 
veloped for  his  age,  of  sound  health  and  physically  fit  for  the  work  at  which  he  is  to  be 
employed. 

3.  Physical  Examinations  for  Children  Entering  Industry. 

A  thorough  medical  examination  for  entrance  into  industry  should  be  required  and 
must  show  that  a  child  is  physically  fit  for  industry.  Before  the  examination  is  made  the 
child  must  bring  a  promise  of  employment  from  his  prospective  employer  stating  the 
specific  occupation  in  which  he  is  to  be  employed. 

4.  Re-examinations  for  Children  Changing  Occupations. 

With  each  change  of  employer  another  examination  should  be  made  before  the  child 
is  again  permitted  to  work,  likewise  when  a  child  is  transferred  in  the  same  place  to  work 
differing  in  its  physical  demands  and  hazards  from  that  for  which  a  permit  is  issued. 

5.  Periodical  Re-examinations  for  All  Working  Children. 

Yearly  medical  examinations  should  be  required  of  all  children  at  work  up  to  the  age 
of  18  years,  or  more  frequently  if  judged  desirable.  These  examinations  shall  take  place 
either  in  the  certificate  issuing  office  or  in  the  place  where  the  child  is  employed. 

6.  Need  of  study  by  local  administrative  and  medical  officers  of  occupations  in 
which  children  are  employed  and  of  their  effect  upon  health. 

Occupations  employing  children  should  be  especially  studied  by  the  examining  physi- 
cian, who  should  also  be  required  to  familiarize  himself  with  conditions  of  employment  and 
the  various  health  hazards  of  industry. 

7.  Need  of  authoritative  scientific  investigation. 

Considerable  further  study  of  the  effects  of  different  kinds  of  work  upon  the  physique 
of  the  adolescent  child  is  necessary,  and  especially  with  reference  to: 

(a)  Comparison  of  the  rate  of  growth  of  children  employed  in  different  occupa- 
tions with  that  of  children  not  in  industry. 

(b)  Comparison  of  morbidity  among  children  employed  in  different  occupa- 
tions with  that  of  children  not  in  industry. 


612  Hospital  and  Health  Survey 

(c)  Comparison  of  mortality  among  children  employed  in  different  occupa- 
tions with  that  of  children  not  in  industry. 

(d)  Fatigue  in  children  employed  in  different  occupations  and  industries. 

(e)  Effect  of  employment  in  specific  occupations  at  different  stages  of  physio- 
logical development  upon  the  growth  and  health  of  (1)  normal  children, 
and  (2)  children  with  certain  physical  defects. 

(f)  Effect  of  employment  in  specific  occupations  upon  the  special  functions 
and  organs  of  adolescent  girls  and  young  women. 

(g)  Types  of  work  desirable  for:  (1)  children  with  some  mental  defect,  and 
(2)  children  who  are  suffering  from  some  physical  handicap. 

Considerable  material  for  these  studies  could  be  obtained  from  public 
school  medical  records  and  records  of  examinations  made  for  work  certificates. 
All  such  records  should  be  standardized  so  as  to  be  statistically  comparable. 

8.   Certain    tentative   minimum   standards  obtainable  from   results  of  scientific 
research  already  available. 

Although  further  study  is  necessary,  there  are  sufficient  data  already  on  hand  to 
justify  the  recommendation  now  of  certain  tentative  minimum  standards,  which  will 
materially  safeguard  the  welfare  of  children  entering  industry  while  still  immature. 

B.     MINIMUM  STANDARDS  OF  PHYSICAL  FITNESS  FOR  CHILDREN 
ENTERING  AND  WORKING  IN  INDUSTRY 

1.  Standards  of  normal  development. 

(a)  Certificates  should  be  refused  to  children  who  do  not  come  up  to  the  fol- 
lowing minimum  standards  of  height  and  weight  for  specified  ages,  based 
on  the  most  reliable  present-day  experience. 

Age  Weight  (in  clothing)  Height 

14  80  lbs.  58  inches 

15  85  lbs.  58  inches 

16  90  lbs.  59  inches 

Exceptions  may  be  made  if  other  circumstances  in  the  child's  case, 
such  as  racial  characteristics,  warrant  it. 

(b)  Certificates  should  be  refused  to  children  who  do  not  show  certain  unmis- 
takable signs  of  adolescence. 

2.  Standards  of  health  and  physical  fitness  for  specific  employment. 

(a)  Certificates  should  be  refused  permanently  to  all  children  who  have  cer- 
tain specified  defects.  All  such  children  should  be  referred  to  the  appro- 
priate agency  for  whatever  assistance  may  be  necessary. 


Health    and     Industry  613 

(b)  Certificates  should  be  refused  to  all  children  pending  correction  of  all 
serious  remediable  defects.  Such  children  should  be  referred  to  the  ap- 
propriate medical  agency  for  the  necessary  medical  treatment. 

(c)  All  children  who,  for  any  reason,  show  a  tendency  to  weakness  or  disease 
of  any  organ  should  be  excluded  from  occupations  which  tend  to  aggravate 
that  tendency. 

C.     POINTS  TO  BE  COVERED  AND  METHODS  TO  BE  EMPLOYED 
IN  PHYSICAL  EXAMINATIONS 

1.  Items  for  Inquiry. 

(a)  First  examination  should  include  a  record  of  sex,  race  and  nationality,  age, 
intended  employer  (name  and  address),  intended  occupation  and  industry,  school  grade 
completed,  family  history  of  father,  mother,  brothers  and  sisters,  previous  illness  and  phys- 
ical examination.     The  physical  examination  should  include  the  following: 

Nasopharynx 

Glands 

Chest,  heart,  lungs 

Abdomen 

Nervous  system 

Summary  of  defects,  as  correctable  and  non-correctable. 

Certificate  should  be  (a)  recommended  after  first  examination,  or  (b)  refused,  either  per- 
manently or  temporarily,  pending  correction  of  specified  defect,  or  (c)  recommended  after 
re-examination  (that  is,  after  correction  of  defect). 

(b)     In  re-examinations  the  same  points   should   be  covered  as  in  the  first 
examination,  and  any  changes  noted  in  detail. 

2.  Record  card  and  instructions  for  use  of  examining  physician. 

The  use  of  a  uniform  record  card  is  recommended  in  order  that  uniformity  may  be 
obtained  in  administration  and  in  statistical  analysis.  Such  a  record  form  is  included  in 
the  report  of  the  committee.  (These  standards  in  full  may  be  obtained  from  the  Federal 
Children's  Bureau,  Washington,  D.  C,  upon  application.) 


EDUCATION'S  RESPONSIBILITY 

More  educational  preparation  for  the  transition  from  school  to  industry 
is  necessary.  Upon  the  training  provided  in  public  education  depends  in  a 
great  measure  the  success  with  which  children  are  guided  out  of  the  school 
period  of  semi-dependence  into  the  industrial  period  of  greater  freedom  and 
final  independence  when  they  must  rely  wholly  on  their  own  efforts. 


Height 

Maturity 

Weight 

Skin 

Physical  condition 

Eyes 

Nutrition 

Ears 

Anaemia 

Mouth 

614  Hospital  and  Health  Survey 

It  is  generally  agreed  that  education's  prime  function  is  that  of  training 
for  citizenship  in  the  complete  sense.  That  this  education  must  contain 
more  elements  which  will  connect  it  with  industrial  life  is  also  generally 
agreed.  When  75%  of  the  children  leave  school  shortly  before  the  comple- 
tion of  the  elementary  grades  to  go  to  work,  it  is  necessary  to  plan  a  course 
of  education  which  will  supply  the  essentials  within  these  grades.  Indus- 
trial experts  believe  that  vocational  training  should  not  be  included  in  ele- 
mentary education  except  in  the  broadest  sense,  that  schools  supported  by 
general  taxation  should  not  be  expected  to  supply  specific  training  for  par- 
ticular jobs,  that  being  the  responsibility  of  industry.  But  the  schools  are 
not  alive  to  their  responsibility  in  getting  children  safely  to  work.  Their 
influence  should  not  cease  as  soon  as  the  child  goes  through  the  school  door. 
Authorities  agree  that  partial  supervision  of  the  child  should  continue  until 
the  child  is  18.  His  public  school  education  should  continue  at  least  as  long 
as  that  in  some  form. 

The  problem  of  incorporating  into  the  school  program  a  sufficient  amount 
of  preparation  for  industrial  life,  of  the  right  sort,  is  one  of  the  most  pressing 
and  fundamental  of  the  many  questions  which  educators  must  face.  Of  the 
various  experiments  already  being  tried  out  none  has  as  yet  proved  itself  of 
sufficient  value  to  justify  its  general  use.  The  problem  has  many  angles 
and  requires  considerable  study  and  experimentation.  The  endeavor  of 
the  National  Association  of  Corporation  Schools  to  gather  data  on  the 
subject  and  to  develop  experimentation  in  industrial  training  as  well  as 
in  general  education  is  a  noteworthy  instance  of  the  many  earnest  efforts 
being  made  to  throw  light  on  a  perplexing  but  interesting  problem,  interest- 
ing because  it  is  of  recent  growth  and  is  an  index  of  the  changing  attitude  of 
society  towards  industry.  It  has  taken  a  long  time  for  general  thought  to 
recognize  that  cultural  education  may  include  knowledge  of  the  industrial 
world  as  well  as  of  the  world  of  letters  and  of  science. 

.  This  problem  cannot  be  solved  easily.  It  is  not  within  the  province  of 
a  health  survey  to  make  specific  recommendations  as  to  how  it  shall  be  done, 
whether  by  more  vocational  training  of  a  general  nature  in  the  school  cur- 
riculum, whether  trade  apprenticeship  in  industry,  or  by  the  exten- 
sion of  the  establishment  of  continuation  schools.  The  Smith-Hughes  Act, 
passed  by  the  United  States  Congress  in  1917,  has  been  a  great  incentive  to 
the  organization  of  some  sort  of  vocational  education  in  all  of  the  states  of 
the  country.  The  local  Board  of  Education  or  the  Ohio  state  educational 
authorities  should  give  this  subject  careful  consideration  in  the  near  future 
and  make  more  adequate  provision  for  industrial  training  in  the  school  pro- 
gram than  exists  at  the  present  time. 

One  element  of  training  for  industrial  life  which  should  be  mentioned 
here  is  that  of  health  education.  Education  for  physical  development  and 
health  maintenance  cannot  begin  too  soon.  Knowledge  of  the  elements  of 
hygiene  and  sanitation  should  be  thoroughly  taught.  For  the  child  entering 
industry  it  is  important  that  he  shall  know  not  only  the  value  of  physical 
and  nervous  energy  and  its  conservation,  but  also  the  particular  health 
hazards  which  he  will  encounter  in  industry.     Trained  to  take  into  account 


Health    and    Industry  •      615 

health  considerations  just  as  he  takes  into  account  wages  and  hours  of  work, 
in  determining  the  relative  merits  of  possible  jobs  he  will  have  learned  a 
valuable  lesson,  and  a  most  useful  one.  As  reported  in  the  section  on  Child 
Health  Work  (Part  III.)  there  is  no  systematic  instruction  in  hygiene  and 
sanitation  offered  to  the  school  children  of  Cleveland  at  present.  A  study 
of  the  subject  brings  out  the  necessity  for  such  instruction  for  children  who 
are  going  into  the  greater  freedom  of  the  industrial  world,  while  they  are 
still  children.  Every  possible  measure  which  can  be  taken  to  teach  them 
to  take  care  of  themselves  contributes  towards  their  development  into 
healthy  adults.  The  Board  of  Education  should  provide  at  once  for  syste- 
matic and  thorough  health  instruction  throughout  the  grammar  grades. 


JUNIOR  VOCATION  DEPARTMENTS 

Nor  is  there  space  in  the  scope  of  a  health  survey  to  do  more  than  indi- 
cate the  problem  of  actual  industrial  placement  of  children  going  to  work 
at  an  early  age.  Sufficient  industrial  training  before  leaving  school  and  care- 
ful selection  of  the  first  jobs  in  industry  are  both  factors  of  influence  in 
assuring  the  establishment  of  sound  health  in  children  of  this  formative  age. 
Not  only  must  a  child  be  adequately  prepared  and  physically  qualified  to 
go  into  industry;  he  must  also  get  into  the  right  place  where  his  individual 
abilities  have  a  chance  for  expansion.  As  pointed  out  previously  a  child 
cannot  be  expected  to  do  this  unaided.  Many  do  and  eventually  make  a 
success  of  their  work,  but  it  is  not  reasonable  to  expect  that  every  child  can 
do  so,  nor  to  assume  that  it  is  anything  more  than  chance  when  a  child  does 
by  accident,  marked  inclination,  or  repeated  trials,  land  in  a  job  which  suits 
him  and  offers  opportunity  for  development.  Provision  should  be  made  for 
continuance  during  the  early  years  of  his  employed  life  of  the  supervision 
by  which  a  child  is  guided  through  school  life.  Some  advice  and  individual 
consideration  for  each  child  going  to  work,  given  by  a  person  familiar  with 
the  various  fields  of  work  open  to  children  and  having  sympathy  with  and 
understanding  of  their  desires  and  inclinations,  can  be  of  great  service  in 
effecting  an  early  adjustment  for  the  child  with  industrial  life.  Vocational 
guidance  is  still  in  the  stage  of  experimentation,  being  one  of  the  many  prob- 
lems concerning  children  of  working  age  which  have  only  recently  received 
attention. 

The  whole  problem  of  inducting  children  from  school  into  industry,  which 
has  been  considered  in  this  study  in  its  relation  to  the  establishment  of  sound 
health  in  youth,  can  be  met  by  the  organization  of  Junior  Employment 
Departments.  England  as  long  ago  as  1910  saw  the  possibilities  of  central- 
ization, and  made  provision  for  it  in  the  Education  (Choice  of  Employment) 
Act.  For  the  past  five  years  even  more  care  has  been  given  to  working 
children  than  provided  for  in  this  act.  Children  going  to  work  have  the 
benefit  of  individual  advice  regarding  work,  of  consideration  of  their  physical 
well-being,  of  educational  opportunity  to  train  for  a  vocation  either  before  or 
after  they  begin  work.  It  is  considered  to  the  nation's  interest  "that  all 
children*  receive  a  good  chance  of  health  and  satisfactory  employment."  In 
England  the  juvenile  labor  exchange  is  under  the  direction  of  the  school. 


616  Hospital  and  Health  Survey 

Junior  employment  departments  or  vocational  guidance  bureaus  are 
developing  in  this  country,  and  it  has  been  found  likewise  advantageous  to 
have  the  department  closely  connected  with  the  school.  When  the  activities 
for  children  of  this  age  are  closely  related  it  is  possible  to  unify  the  efforts  of 
all  and  to  be  sure  that  all  children  are  kept  track  of,  and  all  information  re- 
garding individual  children  made  use  of.  There  are  numerous  reasons  which 
make  advisable  such  centralization  of  activities. 

In  Cleveland  a  free  public  employment  bureau  has  been  in  existence  for 
some  years  under  the  joint  control  of  the  state  and  city  authorities.  This 
bureau  has  conducted  employment  work  for  boys  and  girls  for  some  time. 
The  boys'  work  is  in  a  separate  department.  The  girls'  and  women's  work 
has  been  combined  in  one  department  although  previously  separate.  Careful 
investigation  of  the  work  in  which  young  people  are  employed  and  of  the 
establishments  where  they  are  to  be  sent  has  been  a  prominent  feature  of  the 
junior  employment  work. 

The  work  of  this  department  could  probably  be  more  effectively  carried 
on  in  direct  connection  with  the  Board  of  Education  department  which  has 
supervision  of  all  children  going  to  work.  By  such  a  central  organization 
the  process  of  guiding  children  from  school  to  work  would  be  a  continuous 
one,  under  unified  control  and  direction,  making  contradiction  of  purpose 
impossible.  Free  interchange  of  opinion  and  advice  between  those  ascer- 
taining by  examination  the  abilities  of  children  and  those  directing  them 
into  industry  would  be  possible  and  of  great  value.  All  of  the  data  available, 
relating  to  the  various  phases  of  the  employment  of  children,  would  be  ac- 
cumulated in  one  place  and  their  value  for  research  and  action  be  unequaled. 

Until  such  time  as  it  is  possible  to  effect  a  consolidation  between  the  two 
departments  it  is  recommended  that  their  relations  be  made  as  close  and 
direct  as  possible  in  order  that  the  opinion  of  those  examining  the  child  who 
wishes  to  go  to  work,  may  direct  the  efforts  of  the  employment  bureau  in 
finding  the  child  suitable  employment.  Employment  suited  to  a  child's 
physical  and  mental  abilities  is  essential.  The  degree  of  harmony  attained 
between  a  child  and  his  first  job  has  no  small  influence  in  determining  whether 
he  will  settle  down  and  develop  desirable  work  habits  leading  to  a  well  ori- 
ented character  or  whether  he  is  going  to  be  dissatisfied  in  a  short  time  and 
try  another  job,  drifting  about  until  his  work  habits  become  unsettled  and 
his  character  unstable. 

An  outline  for  such  a  Vocational  Guidance  Department  is  appended.  It 
contains  in  the  plan  of  organization  the  essential  activities  involved  in  deal- 
ing with  the  children  of  working  age,  all  of  which  are  properly  included  in  a 
department  functioning  under  the  Board  of  Education  in  any  city.  Some 
features  included  have  proved  their  value  in  similar  departments  already 
organized  in  this  country  and  abroad.  A  plan  of  this  character  is  appropri- 
ately a  part  of  this  report  as  it  emphasizes  ou  opinion  that  the  problem 
of  the  child  going  into  industry  is  fundamentally  one  of  health,  and 
in  order  to  protect  his  health  adequately  there  must  be  a  central  bureau 


Health    and     Industry  617 

which  will  serve  as  a  bridge  for  his  safe  conduct  from  school  into  the  industrial 
world.  Proper  consideration  of  a  child's  physical  abilities  comes  first.  This 
fact  recognized  and  coupled  with  the  other  factors  which  must  be  considered, 
there  is  no  reason  why  children  should  not  benefit  by  their  early  industrial 
experience,  rather  than  be  permanently  handicapped  if  not  wasted  to  society 
by  their  ill-advised  efforts  at  work,  before  they  are  equal  to  it  or  for  which 
they  are  unfitted.  A  careful  organization  of  the  procedure  of  letting  and 
getting  children  to  work  will  give  the  health  questions  the  important  place 
which  they  should  have,  and  will  provide  adequate  machinery  for  continuing 
the  task  of  supervision  of  children  until  they  reach  maturity. 


Suggested  Plan  of  Organization  tor  a  Junior  Vocational  Bureau 
of  the  Board  of  Education  of  Cleveland 

To  include  boys  15  to  18  and  girls  16  to  18  years  of  age.  This  period  of  years  is  sug- 
gested rather  than  15  to  21  years,  because  it  is  the  division  made  by  the  State  Child  Labor 
Law  between  children  and  adults.  Also  it  simplifies  the  division  of  children's  and  adults' 
employment  into  two  offices,  which  offices  can  then  be  physically  as  well  as  officially 
separate. 

This  organization  will  include  all  steps  in  the  procedure  of  letting  and  getting  a  child 
to  work,  from  the  time  when  he  is  still  in  school  and  thinking  of  going  to  work,  to  the  time 
when  he  is  well  established  in  suitable  employment. 

/.  School  Connections. 

1.  Continuous  record  cards  to  be  used,  containing  the  medical,  mental,  scholastic 
and  social  (including  family)  history  of  the  child,  beginning  with  his  first  year  in  school 
and  following  him  through  the  grades  to -the  office  where  he  makes  application  for  a  work 
certificate.     Such  records  have  been  used  with  great  success  in  other  cities. 

2.  Scholarship  fund  for  children  who  otherwise  would  be  obliged  to  go  to  work  be- 
cause of  economic  necessity. 

3.  Vocational  talks  to  children  who  are  thinking  of  leaving  school,  emphasizing  the 
importance  of  longer  schooling,  but  also  giving  introductory  information  regarding  indus- 
trial life. 

4.  Published  leaflets  on  occupations  open  to  children,  to  contain  ^specific  informa- 
tion relative  to  various  occupations  for  the  benefit  of  children  making  ^ready  to  leave 
school  for  work. 

//.  School  Attendance  and  Illegal  Employment 

The  school  attendance  and  illegal  employment  of  children  of  working  age  must  be 
closely  checked  up  in  order  to  make  certain  that  every  child  going  to  work  does  so  legally 
by  going  through  the  work  certificate  office  where  he  must  undergo  a  medical  examination 
before  receiving  a  work  certificate. 


618  Hospital  and  Health  Survey 


In  order  that  all  information  relative  to  children  15  to  18  years  of  age  may  be  utilized, 
the  school  census  records  should  be  available  at  this  office. 

Special  duties  of  one  or  more  of  the  regular  school  attendance  officers  would  be  to 
follow  up  the  school  attendance  of  children  of  this  age,  to  keep  in  touch  with  the  State 
Factory  Inspection  Department  regarding  children  at  work,  and  to  follow  up  all  cases  of 
children  whose  certificates  have  been  returned,  to  see  that  they  return  to  school  if  not  at 
work.     Correspondence  has  been  successfully  utilized  to  accomplish  some  of  these  ends. 

///.  Issuance  of  Work  Certificates. 

1.  Establishment  of  birth  and  school  records  in  accordance  with  the  legal  require- 
ments. 

2.  Medical  examinations  for  health  certificates,  as  required  by  law.  The  physician, 
nurses  and  clerks  are  to  make  and  record  medical  examinations  and  follow  up  children 
whose  permits  are  held  up,  until  remediable  defects  are  corrected,  or  are  refused  because  of 
physical  disability.  These  children  must  be  kept  track  of,  to  see  that  they  get  medical 
assistance  when  necessary  or  return  to  school  if  not  allowed  to  be  at  work.  The  school 
medical  record  of  a  child  is  of  service  here.     • 

3.  Mental  Tests — At  present  only  marked  subnormality  is  recorded  in  most  offices. 
Intelligence  tests  are  now  used  most  effectively  by  many  large  corporations.  Their  use  in 
this  department  is  essential  in  aiding  in  the  selection  of  suitable  work  for  normal  aS 
well  as  for  subnormal  children. 

IV.  Vocation  Bureau. 

1.  Continuous  research  in  occupations  open  to  children  is  necessary  for  the  purpose 
of  advising  children  wisely  regarding  work,  and  for  the  purpose  of  accumulating  informa- 
tion, in  respect  to  the  health  hazards  for  young  people  in  various  types  of  work.  Too 
little  is  known  on  this  subject  at  the  present  time.  Such  information  must  be  available  to 
the  physician  diagnosing  a  child's  physical  capacity  for  employment. 

2.  Placement  and  Guidance — Connects  children  who  have  received  work  certificates 
with  jobs,  and  has  the  advantage  of  all  the  facts  established  by  previous  examinations  as 
to  the  child's  physical  and  mental  qualifications,  for  use  in  vocational  guidance  work. 

V.  Research. 

Through  the  many  contacts  which  this  bureau  would  have,  and  the  large  amount  of 
information  in  its  files,  special  studies  of  related  questions  would  be  of  value,  as  well  as 
periodical  analysis  of  information  in  the  files. 

VI.  Advisory  Committees. 

Note — In  the  two  months  which  have  elapsed  since  the  field  work  for 
this  report  was  completed,  steps  have  been  taken  by  the  Cleveland  Board  of 
Education  towards  the  formation  of  such  a  bureau.  The  Bureau  of  Attend- 
ance of  the  Board  of  Education  has  been  enlarged  and  its  functions  extended. 


Health     and     Industry  619 

Records  have  been  established  which  will  carry  the  medical,  social  and  school 
history  of  the  child  from  the  time  when  he  first  enters  school  to  the  date 
when  he  leaves  school  to  apply  for  working  papers.  Vocational  advice  to 
such  children  is  to  be  provided,  and  the  possibility  of  arranging  for  employ- 
ment work  is  being  considered.  Greater  emphasis  is  being  put  on  a  child's 
physical  status,  ascertained  by  medical  examinations,  as  the  determining 
factor  in  deciding  whether  or  not  he  shall  receive  a  permit  to  work. 


SUMMARY  OF  RECOMMENDATIONS 
J.  Recommendations  Requiring  Legislation. 

1.  The  Ohio  State  Child  Labor  Law  should  be  amended  in  the  following  particulars: 

Age  Requirements — The  employment  of  boys  before  they  are  16  years  of  age  should 
be  forbidden.  Age  and  schooling  certificates  should  be  required  of  all  boys  under  18 
years  of  age  at  work.     This  makes  the  age  requirements  for  boys  and  girls  the  same. 

In  all  cases  in  the  law  where  an  "age  and  schooling  certificate"  is  mentioned  the  law 
should  be  changed  to  read  "age,  schooling  and  health  certificate,"  inasmuch  as  the  health 
certificate  received  by  the  child  going  to  work  is  one  of  the  most  important  factors  to  be 
considered  in  certifying  a  child  for  employment. 

2.  The  Ohio  School  Code  should  be  amended  in  the  following  particulars: 

Educational  Requirements — Girls  16  to  18  years  of  age  are  not  now  required  to  continue 
school  if  not  employed.  The  law  should  be  amended  to  include  this  requirement  and  to 
make  similar  requirement  for  boys  16  to  18  years  of  age. 

Health  Certificate — The  section  of  the  law  relating  to  a  health  certificate  for  a  child 
going  to  work  should  be  changed.  In  no  case  should  a  child  receive  a  certificate  based  on 
a  previous  record  of  the  child's  health.  A  thorough  medical  examination,  made  by  a 
qualified  physician,  should  be  the  requisite  for  every  health  certificate  issued.  These 
certificates  should  be  issued  in  such  a  manner  and  for  such  periods  of  time  as  to  insure 
periodical  examinations  of  children  over  the  two  years  from  16  to  18,  or  while  they  are 
employed  on  a  certificate  basis.  Every  health  certificate  should  be  issued  for  the  specific 
job  for  which  the  child  makes  application  for  a  permit.  There  should  be  included  a  pro- 
vision for  an  adequate  force  of  examiners  and  assistants,  for  the  work  of  examination  and 
necessary  follow  up. 

Pledge  of  Employer — Added  to  this  section  of  the  law  should  be  a  clause  requiring 
that  the  promise  signed  by  the  employer  specify  the  exact  nature  of  the  work  which  the 
child  is  required  or  permitted  to  do. 

Agricultural  Worli  and  Domestic  Seroice  are  not  now  included  by  the  Ohio  Child  Labor 
Law  in  the  occupations  under  its  supervision.  There  should  be  an  age  limitation  of  at  least  12 
for  these  occupations  and  a  limitation  of  hours  of  work,  similar  to  those  limitations  in  hours 
of  work  in  other  occupations.  A  health  certificate  should  be  required  of  every  child. 
Regulation  of  conditions  of  work  may  involve  some  difficulties  needing   the    cooperation 


6"20  Hospital  and  Health  Survey 

of  other  agencies.     Examinations  for  health  certificates  can  be  conducted  in  the  same  man- 
ner as  for  other  occupations  by  the  existing  machinery  without  great  difficulty. 

3.  The  City  Ordinance  regulating  street  trades  should  be  enforced,  pending  the 
inclusion  of  these  trades  in  the  State  Child  Labor  Law.  Certificates  to  boys  to  engage  in 
this  work  and  badges  to  be  worn  by  them  while  at  work,  as  specified  in  the  ordinance, 
should  be  received  from  the  work  certificate  office  of  the  Board  of  Education,  where  each 
boy  will  receive  a  medical  examination  showing  him  to  be  physically  fit  for  this  kind  of 
work,  before  he  can  receive  a  permit. 

II.  Recommendations  re  Existing  Departments,  State  or  Local. 

1 .  Enforcement  of  the  State  Child  Labor  Law  is  under  the  direction  of  the  Industrial 
Commission  of  Ohio.  The  law  is  not  at  the  present  time  adequately  enforced.  Methods 
of  work  should  be  improved  and  the  personnel  for  inspection  increased,  in  order  to  elimi- 
nate the  illegal  employment  of  children,  the  extent  of  which  the  findings  of  this  study 
indicate. 

2.  Enforcement  of  the  State  School  L  aw  is  similarly  inadequate.  It  is  under  the  direc- 
tion of  the  Board  of  Education.  The  number  of  School  Attendance  officers  should  be  in- 
creased and  the  organization  of  the  Attendance  department  and  the  Work  Certificate 
Office  revised.  The  School  Census  maintained  by  another  department  of  the  Board  of 
Education  should  be  more  closely  related  to  the  department  of  Attendance,  to  aid  in  the 
work  of  checking  up  on  the  attendance  of  children,  and  especially  those  of  working  age. 

3.  Medical  Examination  for  Work.  Certificates — The  present  organization  is  under  the 
direction  of  the  Department  of  Medical  Inspection  of  the  Board  of  Education.  It  needs 
to  be  considerably  expanded  and  its  working  force  increased.  Health  standards  for  chil- 
dren going  into  industry  should  be  formulated,  patterned  after  those  soon  to  be  issued  by 
the  Federal  Children's  Bureau  Committee  on  Health  Standards  for  Children  in  Industry. 
One  of  its  functions,  still  to  be  developed,  should  be  sufficient  contact  with  the  industrial 
field  to  assure  familiarity  with  the  jobs  open  to  children,  in  order  that  the  examining 
physicians  may  be  able  to  decide  intelligently  as  to  the  desirability  of  different  kinds  of 
work  for  the  various  children  examined. 

4.  Mental  Examinations  for  Wor\  Certificates — There  is  at  present  no  means  of  de- 
termining the  mental  capacities  of  children  wishing  to  go  to  work,  other  than  the  school 
record,  which  is  too  brief  to  furnish  any  information  except  the  fact  that  the  child  has 
completed  the  required  school  grade,  except  in  the  case  of  children  who  have  been  known 
in  school  as  markedly  subnormal.  There  should  be  in  close  relation  to  the  work  of  medical 
examination  for  health  certificates  facilities  by  which  to  determine  more  accurately  the 
mental  capacities  of  children  wishing  to  work,  in  order  to  aid  in  the  selection  of  employ- 
ment for  them. 

5.  Educational  Training — More  educational  preparation  for  the  transition  from  school 
to  industry  is  necessary.  It  is  not  within  the  province  of  a  health  survey  to  make  specific 
recommendations  as  to  how  this  shall  be  done,  but  the  Board  of  Education  or  the  State 
educational  authorities  should  give  this  question  careful  consideration  in  the  near  future, 
and  make  provision  for  more  effective  industrial  education.  In  particular  the  Board  of 
Education  should  provide  at  once  for  systematic  and  thorough  health  instruction  in  the 


Health    and     Industry  621 

grammar  grades.  Knowledge  of  the  elements  of  hygiene  and  sanitation  is  essential  to  the 
child  entering  industry  as  well  as  knowledge  of  the  character  of  the  health  hazards  which 
he  will  encounter  in  industry. 

6.  Junior  Employment — The  junior  employment  work  at  present  under  the  direction 
of  the  Public  Employment  Bureau  should  be  carried  on  in  more  direct  connection  with 
that  department  of  the  Board  of  Education  having  supervision  of  all  children  going  to 
work,  in  order  to  have  unified  control  and  direction,  making  contradiction  of  purpose 
impossible.  Until  such  time  as  it  is  possible  to  effect  this  consolidation  it  is  recommended 
that  the  relation  between  the  departments  be  made  close  and  direct,  in  order  that  the 
opinion  of  those  examining  a  child  applying  for  a  work  certificate  may  direct  the  efforts  of 
the  employment  bureau  in  finding  suitable  employment  for  the  child. 

7.  Attendance  Department — Plans  have  been  made  recently  to  enlarge  and  extend  the 
functions  of  the  Attendance  Department  of  the  Board  of  Education.  Sufficient  promi- 
nence should  be  given  to  the  medical  and  mental  examinations  in  all  questions  relating 
to  the  issuance  of  work  certificates  and  to  vocational  guidance,  as  the  medical  and  mental 
examinations,  properly  conducted,  give  unequaled  opportunity  to  make  adjustment  be- 
tween the  law  and  individual  variation  in  capacity  and  physical  development.  More  de- 
pendence should  be  placed  on  the  results  of  careful  examinations  of  children  in  deciding 
as  to  their  employment  in  various  occupations,  thus  lessening  hardship  or  unfairness  in 
individual  cases. 


622 


Hospital  and  Health  Survey 


TABLE  I. 

Classification  of   1,521   Industrial  Organizations  by  Size  Groups 

Including  Employes 

Group  by  Size  of 
Organization 


1 ,000  and  over 

500  and  over 

400  and  over 

300  and  over 

200  and  over 

100  and  over 

1  and  over 

Less  than  1,000 

Less  than      500 

Less  than      400 

Less  than      300 

Less  than      200 

Less  than      100 

1,000  and  over 

500  to  1,000 

400  to      500 

300  to      400 

200  to      300 

100  to      200 

1  to      100 

Totals 1,521  100.00  196,246  100.00 

TABLE  II. 

Medical  Service  in  Industrial  Organizations 

Group  by  Size  of         Total       Number          Total            Total                             Per  Per 

Organizations         Number      Organ.        Number       Number                         Cent  Cent 

Organ.          with         Employes    Employes                      Organ.  Emps. 

in           Medical             in              Recvg.                             in  in 

Group       Service          Group          Service                          Group  Group 

Served  Served 

1,000  and  over 39  32  84,359  72,196  82.05  85.58 

500  to  1,000 41  30  28,176  20,786  73.17  73.77 

200  to      500 102  7  32,029  2,118  6  86  6  61 

1  to      200 1,339  3  51,682  365  0.22  0.70 

Totals 1,521         72         196,246     95,465       4.73     48.64 

1,000  and  over 39  32  84,359  72,196  82.05  85.58 

500  and  over 80  62  112,535  92,982  77.50  82.62 

200  and  over 182  69  144,564  95,100  37.91  65.78 

1  and  over 1,521  72  196,246  95,465  4.73  48.64 


Number  of 
Organizations 

Per  Cent  of  All 
Organiza- 
tions 

Number  of 
Employes 
in  Group 

Per  Cent  of 
All  Employes 
All  Groups 

Average 
Number 
Employes 
per  Organ- 
ization 

39 

2.56 

84,359 

42.98 

2,163.0 

80 

5.25 

112,535 

57.34 

1,406.6 

100 

6.57 

121,362 

61.84 

1,213.6 

134 

8.80 

132,802 

67.67 

991.0 

182 

11.96 

144,564 

73.66 

794.2 

294 

19.32 

155,246 

79.10 

528.0 

1,521 

100.00 

196,246 

100.00 

129.0 

1,482 

97.44 

111,887 

57.02 

75.4 

1,441 

94.75 

83,711 

42.66 

58.0 

1,421 

93.43 

74,884 

38.16 

52.6 

1,387 

91.20 

63,444 

32.33 

45.7 

1,339 

88.04 

51,682 

26.34 

38.5 

1,227 

80.68 

41,000 

20.90 

33.4 

39 

2.56 

84,359 

-  42.98 

2,163.0 

41 

2.69 

28,176 

14.36 

687.2 

20 

1.32 

8,827 

4.50 

441.3 

34 

2.23 

11,440 

5.83 

336.4 

48 

3.16 

11,762 

5.99 

245.0 

112 

7.36 

10,682 

5.44 

95.3 

1,227 

80.68 

41,000 

20.90 

33.4 

129.0 


Per 
Cent 

Emps. 

Served 
of  All 

Emps. 

Per 
Cent 

Organ. 

Served 
of  All 

Organ 

36.78 

2.10 

10.59 

1.97 

1.07 

0.46 

0.18 

0.20 

48.64 

4.73 

36.78 

2.10 

47.37 

4.07 

48.45 

4.53 

48.64 

4.73 

Health    and     Industry 


623 


TABLE  III. 


Personnel  of  Medical  Departments 


Number 

Organ.        Number  of     No.  of     Full- 
Group  by  Size  of  with   Me 
Organization  Service 

1 ,  000  and  over.. 32 

500  to  1,000 30 

200     to    500 7 

1     to     200 3 

Totals 72  95,465         93 


No.  of   No.  of   No.  of    No.  of    No.  of    No.  of 
Part-      Phys.     Trnd.      Prac.      Cleri- 


Employes 
Served 

Ind. 
Disp. 

Time 
Phys. 

Time 
Phys. 

on 
Call 

Nurses 

Nurses 

cal 
Pers. 

72,196 

53 

6 

41 

8 

69 

12 

14 

20,786 

30 

1 

16 

8 

18 

7 

0 

2,118 

7 

0 

4 

1 

6 

0 

0 

365 

3 

0 

1 

1 

0 

1 

0 

62 


18 


93 


20 


14 


TABLE  IV. 
Administrative  Relations  of  Fifty-six  Medical  Departments 

Group  by  Size  of  MEDICAL  DEPARTMENT  RESPONSIBLE  TO 

Organizations                    Administration          Production            Employment                Claims  Total 

1,000  and  over 7                           5                         15                           2  29 

500  to  1,000 8                           5                           8                           0  21 

200    to     500 10                          3                          0  4 

1     to     200 2                           0                           0                           0  2 

Totals 18                         10                         26                           2  56 


TABLE  V. 


Medical  Service  in  Mercantile  Establishments  and  in  Public  Utilities 

No.  No. 

Estab.  No.  of        No.  of  No.  of  No.  of  No.  of      No.  of  No.  of        with 

with  Dis-            Em-  Full-  Part-  Phys.        Trnd.  Prac.         Vistg. 

Medical  pen-          ployes  Time  Time  on          Nurses  Nurses       Nurs- 

Service  saries        Served  Phys.  Phys.  Call  ing 

Mercantile 6  69, 107  1  3  2              5  2              2 

Public  Util 6  7          13,302  0  7  16  12 

Totals 12  13         22,409  1  10  3           11  3             4 


624  Hospital  and  Health  Survey 

TABLE  VI. 

Accident   Frequency  and   Severity   Rates   for   Cuyahoga   County 

Based  Upon  Ohio  Industrial  Commission  Report  for 

July  to  December,  1914 

For  six  months  period: 

Accidents  causing  death 44 

Accidents  causing  permanent  partial  disability.. 330 

Accidents  causing  disability  over  seven  days 3,892 

Accidents  causing  disability  two  to  seven  days..... 4,571 

Time  Loss: 

Cases  fatal  (6,000  days  each) _ 264,000  days 

Permanent  partial  disability 52,127  days 

Temporary  disability,  over  seven  days 103,976  days 

Temporary  disability,  under  seven  days 9 ,  199  days 

Total  time  loss,  all  accidents,  six  months 429,302  days 

Accepting  estimate  of  Bulletin  9   (1915),   Industrial  Commission,  employes  in  industry 
numbered  185,000. 

Estimated  number  reportable  accidents  annually 17,344 

Frequency  rate  (number  per  1,000  full-time  workers) 93.7 

Estimated  number  days  lost  per  year..... 858 ,  604 

Severity  rate  (  days  lost  per  worker  per  year) 4.53 


TABLE  VII. 

Accident  Frequency  and  Severity  Rates  for  Groups  of  Operatives 
Employed  Within  Selected  Areas 

Based  Upon  Reports  Furnished  by  the  Industrial  Commission  of  Ohio  Covering 
the  Period  of  June  1st  to  November  30th,  1919 


Group 

Number 

of 
Employes 

Accidents  During  Six 
7  Days 
and 
Fatal           Less 

Months 

More 

than 
7  Days 

Estimated 
Yearly 
Total 

Freq. 
Rate 

Estimated 

Yearly 
Time  Loss 

Sever- 
ity 
Rate 

I. 

24 , 298 

3 

905 

215 

2,246 

92.4 

33,927 

1.3 

II. 

19,600 

6 

2,147 

520 

5,346 

276.3 

74,345 

3.7 

III. 

10,193 

2 

1,371 

287 

3,320 

325.7 

33,945 

3.3 

Totals       54,091  11  4,423  1,022  10,912  201.7  142,217  2.6 

Time  losses  were  estimated  by  reckoning  a  fatal  accident  as  equivalent   to  6,000  days. 

Employing  average  values  previously  published  by  the  Industrial  Commission,  tem- 
porary disability  of  seven  days  or  less  was  reckoned  at  2.1  days;  temporary  disability  of 
more  than  seven  days,  at  28.2  days. 


Health    and    Industry  625 


TABLE  VIII. 

Comparative  Accident  Frequency  and  Severity  Rates  in  the  Con- 
struction and  Metal  Trades 

Based  Upon  Statistics  Published  by  the  Industrial  Commission  of  Ohio  for 
Cuyahoga  County,  July  to  December,  1914 

Construction  Metal 

Trades  Trades 

Number  of  employes 20 ,  000               72 ,900 

Accidents  (6  months): 

Fatal 19                   10 

Permanent  partial  disability 30                   71 

Temporary  disability 1 ,  393             3 ,  825 

Total  number  accidents 1,442             3,906 

Accidents  (calculated  for  one  year) 2  ,884             7,812 

Accident  frequency  rate 144.2              107.1 

Corrected  for  assumed  10-hour  day,  200-day  year 216.3 

Corrected  for  assumed  8-hour  day,  200-day  year 270.3 

Calculated  time  loss,  days  per  year '. 290 ,  868       246 ,  858 

Accident  severity  rate 14.5               3.38 

Corrected  for  assumed  10-hour  day,  200-day  year *     21.0 

Corrected  for  assumed  8-hour  day,  200-day  year : 27.2 

The  corrections  above  noted  are  made  in  consideration  of  the  fact  that  many  workers 
in  the  construction  trades  do  not  work  a  3,000-hour  year,  which  is  the  normal  basis  of 
computation  of  frequency  and  severity  rates. 

The  time  losses  given  in  this  table  were  calculated  from  those  published  by  the  Indus- 
trial Commission,  with  the  exception  of  allowances  for  fatal  accidents,  which  were  reckoned 
as  each  equivalent  to  a  loss  of  6,000  days. 


626 


Hospital  axd  Health  Survey 


TABLE  IX. 

Classification  of  79  establishments  employing  women,   presenting  numbers  of 

various  establishments,  numbers  of  women  therein  employed, 

and  group  totals. 


Group 

Industrial 

No.  of 
Establish- 
ments 

23 
11 

7 

6 

3 

2 

5 

Group 
Total 

57 

Nature  of 
Group  Members 

Metal  Trades 

No.  of 
Female 

Employes 

...     3,691 

Group 
Total 

Knitting  and  Textile 

...     4,642 

Garment  Trades 

...     2,700 

Candy  Factories 

371 

Paper  Box  Factories 

220 

Tobacco  Factories 

375 

614 

12,613 

Mercantile 

7 

7 

Department  Stores 

6,730 

Personal  Service.          . 

6 
3 
2 

11 

Laundries 

Hotels 

Restaurants 

505 
708 
245 

- 

1,458 

Public  Utilities 

2 
2 

4 

Telephone  Companies 
Telegraph  Companies 

1,675 
430 

2,105 

Totals 

.       79 

22,906 

Health    and    Industry 


627 


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Hospital  and  Health  Survey 


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629 


TABLE  XII. 

Classification  of  starting  weekly  wage  rates  for  women  in  55  industrial 
establishments  employing  women. 


Group 

12-13 
Dollars 

13-14 
Dollars 

14-15 
Dollars 

15-16 
Dollars 

16-17 
Dollars 

17-17.50 
Dollars 

Totals 

Metal. 

1 

7 

6 

5 

2 

21 

Knitting  and  Textile.. 

4 

2 

2 

2 

1 

— 

11 

Garment 

1 

5 

1 



— - . 

7 

Candy 

j 

4 



.... 

2 

— 

6 

Miscellaneous 

3 

1 

2 

2 

2 

10 

Totals 

8 

8 

16 

11 

10 

2 

55 

TABLE  XIII. 


Classification  of  luncheon  facilities  in  56  industrial  establishments 
employing  women. 

Lunchroom  Selling  No 

Supplementary  Lunchroom        Lunchroom 

Group                                                  Cafeteria               Lunch  Only  Used              Totals 

Metal 11                      3  7  2                  23 

Knitting  and  Textile 5                    ....  3  3                  11 

Garment. 3                      1  3  ....                   7 

Candy , 2                    ....  2  15 

Miscellaneous _ 2                     ....  8  ....                10 

Totals 23                      4  23  6                 56 


630 


Hospital  and  Health  Survey 


,  TABLE  XIV. 

Classification   of  33  industrial   establishments  employing  women  and   having 

centralized  employment  service,  by  size-groups  based  on  total 

number  of  employes. 


Group 

Metal 

Knitting  and  Textile. 

Garment. 

Candy : 

Miscellaneous...- 

Totals 


1,000  and 
Over 

500  to  1,000 

200  to  500 

1  to  200 

Total 

6 

3 

6 

1 

16 

1 

3 

0 

0 

4 

0 

5 

1 

1 

7 

0 

0 

1 

2 

3 

1 

0 

0 

2 

3 

11 


33 


TABLE  XV. 

Classification   of  23  industrial   establishments  employing  supervisory  women, 
by  size-groups  based  on  total  number  of  employes. 


Group 

Metal...„ 

Knitting  and  Textile. 

Garment 

Candy 

Miscellaneous 

Totals 


1,000  and 
Over 

500  to  1,000 

200  to  500 

1  to  200 

Total 

4 

0 

3 

0 

7 

0 

4 

0 

0 

4 

0 

5 

0 

1 

6 

0 

0 

1 

3 

4 

0 

0 

0 

2 

2 

23 


Health    and    Industry 


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632  Hospital  and  Health  Survey 

TABLE  XVII. 
Number  of  Children  at  Work,  By  Age  and  Sex 

From  the  Work  Certificate  Records,  September,  1918  to  September,  1919 

Permits  Vacation  Total 

September,  1918  to  Permits  Number 

June,  1919  June-September,  1919  at  Work 

Boys 1,444  581  2,025 

Girls 2,057  546  2,603 


Total 3,501  1,127  4,628 


TABLE  XVIII. 
Number  of  Children  at  Work,  By  Age  and  [Sex 

From  the  Records  of  the  Industrial  Commission  of  Ohio,  1919 

Clerical  Wage  Sales  Total 

Workers  Earners  People  Workers 

Boys 617  2,248  92  2,957 

Girls 573  1,416  83  2,072 


Total 1,190  3,664  175  5,029 


TABLE  XIX. 
Comparison  of  Tables  16-18  for  Number  of  Children  at  Work 


Boys 
Girls.. 


School  Census 
Ages  15-18 

Work  Certificate 

Records. 

Ages  15-16  and 

16-18 

Ind.  Commission 

Records. 

Ages  15-18 

9,068 

1,444 

2,957 

(15-18) 

(15-16) 

(15-18) 

6,778 

2,057 

2,072 

(16-18) 

(16-18) 

(16-18) 

Total 15,846  3,501  5,029 


Health    and     Industry  633 


TABLE  XX. 
Occupations  Employing  Children  Under  18,  By  Age  and  Sex 

Analysis  of  Records  of  Industrial  Commission  of  Ohio,  1919 

Trade,  Telephone 

Construe-       Manufac-  Retail  and  and 

tion                turing               Service  Wholesale  Telegraph        Total 

Boys — 

Clerical  Workers 15                 309             116  157  20               617 

Wage  Earners 67             1,778               56  316  31           2,248 

Salespeople 1                     3               ....  88  ....                 92 

Total..... 83      2,090      172  561  51     2,957 

Girls- 
Bookkeepers 12                  205               92  187  77               .573 

Wage  Earners 688               43  299  386           1,416 

Salespeople 6               ....  77  ....                 83 

Total.-.. 12       899      135  563  463     2,072 

Total- 
Clerical  Workers 27                  514             208  344  97           1,190 

Wage  Earners 67             2,466               99  615  417           3,664 

Salespeople..... 1                     9              ....  165  _..              175 


Grand  Total 95  2,989  307  1,124  514  5,029 


Per  Cent  of  Total  Number  Employed  of  Each  Group  by  Sex 

Clerical  Workers  Wage  Earners  Sales  People  Total 

No,  Per  Cent  No.  Per  Cent         No.         Per  Cent  No.        Per  Cent 

Boys..- 617       20.9%         2,248         76.0%         92         3.1%         2,957       100% 

Girls™ 573       27.6%         1,416         68.4%         83         4.0%         2,072       100% 


Total 1,190       23.7%         3,664         72.8%       175         3.5%         5,029       100% 


634  Hospital  and  Health  Survey 


TABLE    XXI. 

Distribution  of  Children  in  All  Occupations  and  in  Leading  Manu- 
factures for  1915  and  1919 

From  the  Records  of  the  Industrial  Commission  of  Ohio,  1915  and  1919 

Boys  Girls 

Occupation  1915  1919  1915  1919 

Construction __ »      58 

Manufacturing 1 ,638 

Service 37 

Trade,  Retail  and  Wholesale _ 323 

Telephone  and  Telegraph  Work _ 44 


83 

0 

12 

2,090 

859 

899 

172 

6 

135 

561 

299 

563 

51 

35 

463 

Total 2,100  2,957  1,199  2,072 


Leading  Manufacturers 

Autos  and  Auto  Parts 

Bolts,  Nuts,  Etc.... 

Clothing,  Men's  and  Women's 

Confectionery 

Copper,  Tin,  Etc 

Electrical  Machinery 

Foundry  and  Machine  Shop  Products.... 

Gas  and  Electric  Fixtures 

Hosiery  and  Knit  Goods 

Printing  and  Publishing _. 

Sewing  Machines... 

Steel  Works  and  Rolling  Mills.. 

Woolen  and  Worsted  Goods 

Total 849  1,423  580  686 


Boys 

Girls 

1915 

1919 

1915 

1919 

66 

120 

53 

18 

44 

76 

6 

3 

26 

37 

286 

115 

8 

0 

32 

76 

76 

61 

0 

19 

71 

277 

14 

53 

200 

334 

12 

53 

24 

96 

23 

187 

36 

15 

121 

29 

202 

242 

26 

81 

0 

160 

0 

10 

76 

4 

0 

0 

20 

1 

7 

42 

Health    and    Industry  635 

TABLE  XXII. 
Weekly  Wage  Rates  for  Children  By  Occupation  and  Sex 

From  the  Report  of  the  Industrial  Commission  of  Ohio  for  1919 

Trade,        Telephone 
Construe-     Manufac-  Retail  and  and 

Weekly  Wages  tion  turing  Service        Wholesale     Telegraph         Total  Total 


75 


47 


88 


100 


338 


Under  $5.00 — 

Boys 0 

Girls 0 

$5.00-$6.00— 

Boys 1 

Girls .-„  0 

$6.00-$7.00— 

Boys 7 

Girls 1 

$7.00-$8.00— 

Boys 5 

Girls 0 

$8.00-$10.00— 

Boys 34 

Girls 0 

$10.00-$12.00— 

Boys 14 

Girls 1 

$12.00-$15.00— 

Boys 11 

Girls 5 

$15.00-$18.00— 

Boys 4 

Girls 2 

$18.00-$21.00— 

Boys 2 

Girls _.  1 

$21.00-$25.00— 

Boys 3 

Girls 1 

$25.00-$30.00— 

Boys 1 

Girls 0                    6                2                     1                5                  14                58 

$30.00-$35.00— 

Boys 1 

Girls 1 


20 

4 

29 

1 

54 

2 

2 

17 

0 

21 

13 

3 

23 

1 

41 

4 

0 

2 

0 

6 

8 

5 

35 

2 

57 

1 

5 

24 

0 

31 

31 

11 

19 

5 

71 

14 

7 

8 

0 

29 

87 

23 

74 

11 

229 

47 

9 

49 

4 

109 

268 

43 

109 

12 

446 

201 

40 

177 

328 

747 

567 

49 

138 

10 

775 

3  71 

33 

172 

86 

667 

473 

16 

87 

6 

586 

178 

14 

83 

20 

297 

424 

19 

40 

0 

485 

57 

14 

23 

8 

103 

154 

0 

4 

2 

163 

18 

5 

7 

10 

41 

42 

0 

0 

1 

44 

6 

2 

1 

5 

14 

3 

1 

3 

0 

8 

0 

2 

0 

2 

5 

1,193 


1,442 


883 


588 


204 


Total..._ 95     2,989     307     1,124     514     5,029    5,029 


636 


Hospital  and  Health  Survey 


TABLE  XXIII.  A 

Analysis  of  Records  of  100  Newsboys  in  Cleveland,  Showing  Age, 
School  Grade  and  Mental  Capacity 


School  Grade 

Mental 

Capacity 

\ge 

I. 

II. 

III. 

IV. 

V. 

VI. 

Total 

Good 

Fair 

Poor 

Total 

6 

4 

.... 

.... 

.... 

4 

1 

2 

1 

4 

7 

1 

3 







4 

2 

2 

4 

8 

6 

2 

8 

3 

4 

1 

8 

9 

2 

2 



4 

3 

1 

4 

10 

1 

.... 

2 

5 

4 

12 

7 

3 

2 

12 

11 

1 



2 

5 

12 

1 

21 

11 

5 

5 

21 

12 

(Special 

2) 

10 

5 

17 

9 

5 

3 

17 

13 

(Special 

6) 

2 



5 

12 

25 

8 

11 

6 

25 

14 

.... 



2 

1 

3 





3 

3 

15 

.... 

.... 

.... 

.... 

1 

1 

2 

2 

2 

rotai 

[        7 

11 

10 

10 

34 

20 

100 

44 

31 

25 

100 

TABLE  XXIII.  B 

Analysis  of  Records  of  100  Newsboys,  Continued,  Showing  Age, 
Health  and  Hours  of  Work  at  Night 


Health 


Age      Good    Fair     Poor    Total 


6 

3 



1 

4 

7 



1 

3 

4 

8 

4 

1 

3 

8 

9 

1 

1 

2 

4 

10 

6 

2 

4 

12 

11 

8 

3 

10 

21 

12 

8 

4 

5 

17 

13 

17 

3 

5 

25 

14 

3 



3 

15 

1 

1 

2 

Total 

51 

15 

34 

100 

Work  Till  Night 

5 

6 

7 

8 

9 

10 

Total 

2 

1 

1 

4 

1 

2 

1 

4 

5 

1 

1 

1 

8 

1 

1 

2 



4 

3 

4 

1 

1 

1 

2 

12 

3 

9 

5 

2 

1 

1 

21 

2 

9 

2 

3 

1 

17 

3 

12 

2 

4 

3 

1 

25 

1 

1 

1 

3 

2 

.... 

2 

19 


40 


14 


14 


100 


Health    and    Industry 


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THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child]Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,| Dentistry,  Pharmacy. 

IX.    Nursing. 

X.     Hospitals  and  Dispensaries. 

XI.     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 

The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 

THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Premier  Press 

Cleveland,  O. 


Education  and    Practice   in 

Medicine,  Dentistry, 

Pharmacy 


Part  Eight 


Cleveland    Hospital     a  n*d 
Health    Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anisfield  Bldg. 
Cleveland    -  Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

D,r.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators : 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

I.     Medical  Education  and  Practice  in  Cleveland. 

Medical  College  of  Western  Reserve  University.                                         - .        •  Page 

Position  in  Community 65 1 

Present  Problems  of 

Construction '..1 1 '. ! 653 

Endowment .  654 

Community  Relations 655 

Discussion  of  Instruction  Now  Offered : 656 

History  of  the  College  and  the  Distribution  of  its  Graduates '.....  659 

Post-graduate  Instruction : 662 

Medical  Practice 

Classification  of  Cleveland  Physicians  by  Specialties _ 663 

Hospital  Staff  Service 664 

Professional  Organizations. 664 

Discussion  of  Autopsy  Service 667 

Recommendations 669 

II.  Quacks  and  Patent  Medicines,  in  Relation  to  the  Foreign  Born  of  Cleveland. 

The  Picture 

The  Immigrant — Susceptibility  of  foreign  temperament 672 

The  Quack    672 

How  the  Quack  Reaches  the  Immigrant 674 

The  Objectives 

Means  of  Investigation  and  Prevention.. 676 

Means  of  Prevention 

Education  of  Public 677 

Regeneration  of  Foreign  Language  Newspapers.... 678 

Counter  Attractions 678 

Recommendations 682 

III.  Dentistry  in  Cleveland 

Private  Practice  of  Dentistry 683 

Free  Dental  Work 

At  public  schools 684 

At  3  health  centers 684 

At   City   Hospital 685 


TABLE  OF  CONTENTS— Continued 

III.  Dentistry  in  Cleveland — Continued  Page 

Dental  Service  at  College  of  Dentistry..... 685 

Dental  Service  in  Hospitals 686 

College  of  Dentistry.... 1 688 

The  Dental  Hygienist 689 

Recommendations 690 

IV.  Pharmacy  in  Cleveland 

Number  and  Education  of  Pharmacists. 691 

Laws  Dealing  with  Pharmacy 

Enforcement  of  Law 692 

Abuses  Which  Are  Tolerated... 693 

Cooperation  of  Pharmacists  with  the  Division  of  Health 694 

School  of  Pharmacy  of  Western  Reserve  University 

History 694 

Buildings 695 

Faculty _ _ 695 

Finances...- 695 

Needs __ 695 

Proposed  Manufacturing  and  Professional  Service  for  Hospitals 696 

Recommendations 697 


Medical    Education   and    Practice 
in  Cleveland 

By  Haven  Emerson,  M.  D. 

SCHOOL  OF  MEDICINE  OF  WESTERN  RESERVE  UNIVERSITY 

WHERE  there  is  but  one  institution  of  learning  in  a  community,  deal- 
ing with  education  in  the  liberal  professions  primarily  concerned 
with  the  prevention  and  care  of  disease,  the  responsibility  for  pro- 
grams and  accomplishment  is  easy  to  fix  and  the  resources  to  be  looked  to 
for  advancement  are  sharply  limited.  In  Cleveland  through  eliminations, 
mergers  and  absorptions  the  Western  Reserve  University  finds  itself  at  the 
moment  the  only  institution  in  Cleveland  responsible  for  the  preparation  of 
physicians,  dentists  and  pharmacists  for  the  legal  practice  of  these  profes- 
sions. For  nurses  also  the  only  agency  offering  education  in  the  public 
health  field  is  provided  by  the  University. 

Since  public  service  in  the  field  of  medical  practice  and  in  preventive 
medicine  can  not  rise  higher  than  its  source,  it  is  natural  that  where  failures 
of  imagination,  scope,  technic  and  standards  in  the  professions  are  found 
the  inquirer  turns  to  the  University  to  seek  the  cause.  University  education 
is  subject  to  the  same  three  main  limitations  as  affect  education  in  general 
and  they  are  apparently,  in  the  order  of  their  importance,  the  ideals  of  the 
teachers,  the  character  of  administrative  leadership  and  organization,  and 
the  material  resources  to  provide  the  teachers  and  the  facilities  for  their 
development. 

For  the  noticeably  deficient  recognition  by  the  laity  and  by  the  medica 
profession  of  Cleveland,  of  many  specialties  in  medicine  which  now  demand 
long  preparation,  exclusive  devotion  and  constant  study  in  order  to  reap  the 
benefit  and  provide  the  service' which  modern  knowledge  permits,  we  can 
not  but  hold  the  policies  of  the  medical  teachers  responsible.  Under  both 
medicine  and  surgery  important  and  necessary  special  branches  have  devel- 
oped elsewhere  which  are  not  provided  for  in  Cleveland.  In  tuberculosis, 
cardiology,  neurology,  psychiatry,  urology,  industrial  and  preventive  medi- 
cine, and  orthopedics,  opportunities  have  been  and  are  still  lost  which  the 
medical  school  owes  to  students,  practitioners  and  the  sick  of  the  city.  There 
is  much  encouragement  in  the  fact  that  during  the  past  college  year  de- 
cisions have  been  reached  which  should  broaden  the  field  of  surgery  by  pro- 
viding for  a  department  of  orthopedics  having  a  large  measure  of  independent 
development,  and  under  the  general  head  of  medicine  will  arrange  for  a  de- 
partment of  psychiatry  and  neurology  with  obligations  to  provide  for  the 
necessary  clinical  teaching  in  these  specialties.  Much  more  could  still  be 
done  to  encourage  and  assist  undergraduate  students  and  recent  graduates 
to  cultivate  new  and  special  fields  in  research  and  practice  as  is  common  in 
other  centers  of  medical  education. 


65Z  Hospital  and  Health  Survey 

The  contact  made  with  a  wide  circle  of  workers  in  medical  and  kindred 
fields,  especially  among  those  concerned  with  the  social  and  preventive  appli- 
cation of  medical  sciences  in  Cleveland,  gradually  developed  the  conviction 
among  the  members  of  the  Survey  staff  that  the  regard,  respect,  dependence 
and  affection  felt  by  the  public  for  the  University  fall  far  short  of  what  one 
might  expect.  Little  exact  knowledge  was  found  to  be  possessed  concerning 
many  of  the  important  problems  of  medical  and  dental  education  by  those 
in  responsible  positions  as  trustees  and  executives. 

In  the  Medical  School  the  constitution  and  activities  of  the  executive 
committee  of  the  faculty  seem  to  meet  all  the  needs  and  yet  contact  between 
the  faculty  and  the  trustees  is  on  an  uncertain  and  unsatisfactory  basis. 
Definite  assignment  of  duties  and  responsibilities  are  not  called  for  from  the 
trustees.  It  is  a  matter  of  first  importance  that  the  appeal  for  support 
for  education  should  be  based  on  recognition  by  the  public  of  eminent  ser- 
vice given  to  it  by  the  University,  and  upon  entire  confidence  in  the  practical 
value  of  the  training  given  and  of  the  researches  undertaken. 

In  the  words  of  the  business  salesman,  the  University  has  not  sold  itself 
to  the  Cleveland  public.  Leadership,  organization  and  service  are  needed 
with  this  object  in  view. 

To  this  end  it  is  suggested  that  much  strength  to  the  University  organi- 
zation might  be  expected  by  enlisting  the  active  interest  and  work  of  trus- 
tees who  are  still  in  the  midst  of  the  actual  problems  of  industry,  professions 
and  public  service,  as  well  as  those  to  whom  the  honor  of  trusteeship  is 
rather  a  recognition  of  past  accomplishments  and  of  readiness  to  be  generous 
in  financial  support. 

Among  the  trustees  should  be  those  chosen  by  the  alumni  of  the  various 
professional  schools  from  their  own  professions,  officially  delegated  to  repre- 
sent the  graduates.  From  no  representative  group  of  citizens  will  be  found 
those  who  will  serve  the  University  more  faithfully  or  bring  to  its  councils 
more  vision,  ideals  and  influential  support  than  from  the  body  of  graduates 
of  the  Medical  School. 

As  to  the  third  element  in  determining  a  university's  ability  to  meet  its 
public  obligations:  namely,  material  resources  for  teaching  and  research, it  is 
worth  noting  that  at  the  present  time  when  building  costs  are  so  exorbitant 
and  teachers  of  all  kinds  are  so  ill  paid,  the  simplest  business  logic  will  advise 
investment  largely  in  men,  brains  and  service  with,  for  the  time  being,  no 
more  outlay  on  buildings  than  is  necessary  to  give  adequate  facilities  for  the 
teachers,  the  classes  and  such  research  as  can  only  be  done  within  University 
buildings.  Once  the  relative  importance  of  the  various  financial  needs 
which  the  professional  colleges  face  is  outlined,  the  generosity  and  pride  of 
Clevelanders  in  their  important  public  undertaking,  the  Western  Reserve 
University,  can  be  counted  on  to  find  the  funds. 


Professional  Education  and  Practice  653 

Problems  of  Construction  and  Endowment 

In  considering  the  relative  importance  of  the  two  large  undertakings 
which  face  the  trustees :  namely,  the  erection  of  new  Medical  School  build- 
ings and  endowment  or  more  adequate  financial  support  for  the  teaching 
departments  of  the  Medical  School,  and  the  erection  and  maintenance  of  a 
University  Hospital  Group,  a  few  fundamental  statements  of  fact  and  ex- 
pressions of  opinion  are  offered  before  presenting  concrete  recommendations 
for  order  of  procedure,  as  suggested  for  the  consideration  of  the  Board  of 
Trustees. 

In  the  first  place,  the  University  now  controls  at  City  Hospital,  at  Lake- 
side, at  the  Maternity  Hospital  and  at  the  Babies'  Dispensary  and  Hospital, 
such  facilities  for  clinical  teaching  as  meet  the  most  ambitious  needs  for  the 
highest  grade  of-  medical  education,  and  very  broad  opportunities  for  re- 
search in  both  laboratory  and  clinical  branches  of  medical  science. 

At  Lakeside  and  at  City  Hospital  936  beds  offering  clinical  material  in 
medicine,  surgery,  pediatrics,  contagious  diseases,  tuberculosis,  venereal  dis- 
ease and  mental  disease  are  available  and  under  exclusive  University  control 
for  12  months  in  the  year.  Twenty-two  beds  for  maternity  cases  and  1,500 
confinements  a  year  in  in-  and  out-patient  services  are  available  for  teaching 
purposes.  With  the  proposed  doubling  of  the  capacity  of  City  Hospital,  to 
which  the  city  committed  itself  by  vote  at  the  primary  elections  in  April, 
1920,  the  field  for  clinical  study  at  that  hospital  will  be  still  further  increased. 
The  City  Hospital  will  probably  always  include  groups  of  patients  who  can- 
not legally  be  cared  for  except  in  such  a  public  hospital.  The  City  Hospital  will, 
in  all  probability,  always  have  a  larger  group  of  patients  available  for  clinical 
instruction  in  contagious  diseases,  tuberculosis,  venereal  diseases,  mental  and 
nervous  diseases,  chronic,  incurable  and  inoperable  medical  and  surgical 
cases  than  are  likely  to  be  or  should  be  accommodated  in  any  privately  con- 
trolled institution,  even  if  devoted  exclusively  to  teaching  purposes.  The 
value  of  this  asset  in  clinical  teaching  can  hardly  be  over-emphasized. 

The  close  physical  situation  of  Medical  School  buildings,  in  relation  to 
the  home  of  other  faculties  of  the  university  departments,  is  considered  very 
desirable,  if  not  absolutely  essential,  for  the  broadest  and  most  catholic 
relationship  between  the  various  teaching  groups. 

The  control  by  a  university  medical  school  of  its  own  hospital,  in  order 
to  permit  of  intensive  study  and  special  methods  of  education  in  groups  of 
patients  selected  particularly  for  their  value  in  medical  education  and  re- 
search, is  considered  entirely  desirable  and  the  complete  dependency  of  a 
medical  school  upon  a  public  department  for  its  sole  hospital  facilities  is  not 
considered  safe  in  the  present  crude  and  politically  precarious  condition  of 
municipal  government  in  Cleveland,  as  elsewhere  in  the  United  States.  The 
physical  separation  of  the  City  Hospital  from  the  Medical  School  buildings, 
which  it  may  be  presumed  will  ultimately  be  located  in  the  vicinity  of  the 
University  campus,  would  not  necessarily  put  any  particular  inconvenience 
in  the  way  of  its  use  by  medical  students,  although  the  time  of  medical 


654  Hospital  and  Health  Survey 

teachers  might  be  wasted  to  a  slight  degree  unless  there  were  certain  labora- 
tory or  research  facilities  added  to  the  City  Hospital  equipment  at  the  ex- 
pense of  the  University. 

It  is  believed  that  the  first  project  for  which  money  should  be  raised  and 
plans  made  for  construction,  equipment  and  maintenance,  is  a  building  or 
buildings  for  the  Medical  School,  to  include  the  various  facilities  needed  for 
teaching  and  research,  such  as  can  be  carried  on  outside  of  the  immediate 
walls  of  the  hospital. 

It  is  recommended  that,  at  the  same  time  that  the  project  for  Medical 
School  buildings  is  undertaken,  the  trustees  prepare  a  plan  for  the  financial 
support,  either  by  endowment  or  with  annual  pledges,  which  will  provide 
adequately  for  the  salaries  and  service  needs  of  each  department,  so  as  to  in- 
sure the  provision  of  personnel  to  give  the  University  a  100%  return  for 
its  investment  in  its  greatest  asset — the  brains  of  its  teachers. 

It  is  recommended  that  the  trustees  of  the  University  devote  their  best 
efforts  to  accomplish  such  changes  as  may  be  needed  in  the  City  Charter 
and  such  action  as  may  be  necessary  from  the  officers  of  the  city  government 
as  to  insure  the  appointment  of  trustees  selected  from  representative  groups 
of  citizens  by  the  Mayor,  to  be  responsible  for  the  administration  of  the 
City  Hospital.  In  support  of  this  recommendation  it  must  be  said  that 
the  University  has  a  greater  stake  in  the  permanency  of  policy,  in  the  non- 
political  character  of  administration,  and  in  the  standard  of  equipment, 
service  and  support  given  to  the  City  Hospital  than  has  any  other  group 
in  the  community.  It  would  probably  cost  upward  of  $25,000,000  at 
present  construction  costs  for  the  University  to  obtain,  through  private 
means,  anything  approximating  the  range  of  material  for  clinical  teaching 
that  will  be  available  and  at  their  service  at  the  enlarged  City  Hospital.  It 
must  be  noted  that  the  value  of  this  material  in  medical  education  is  now 
and  always  will  be  jeopardized  by  political  mischief  or  accident  until  the 
present  method  of  appointing  the  superintendent  of  City  Hospital  and  his 
responsibility  practically  direct  to  the  Mayor,  to  whom  alone  he  is  indebted 
for  his  appointment,  is  replaced  by  a  method  of  appointment  and  adminis- 
tration which  resembles  more  closely  the  system  found  necessary  to  insure 
continuous  and  high  grade  hospital  policies  and  administration  in  private 
institutions  under  boards  of  trustees.  It  is,  furthermore,  felt  that  the  Uni- 
versity owes  to  the  public  the  use  of  its  prestige  and  influence  to  get  the  City 
Hospital  out  of  politics,  if  for  no  other  reason  than  that  the  sick  poor  at 
City  Hospital  are  entitled  to  as  constant  and  scientific  medical  service  as 
the  University  would  expect  to  provide  in  its  own  privately  controlled  insti- 
tutions. 

When  the  above  three  main  accomplishments  have  been  successfully 
carried  to  completion  or  have  been  brought,  by  the  efforts  of  the  University, 
within  promise  of  accomplishment,  and  when  funds  have  been  obtained 
which  would  justify  undertaking  a  building  program,  at  a  cubic  foot  cost  for 
construction  considerably  less  it  is  hoped  than  prevails  at  the  present  time, 


Professional  Education  and  Practice  655 

the  plans  of  the  University  Trustees  for  a  joint  hospital  project,  involving 
the  Babies'  Hospital,  Maternity  Hospital  and  Lakeside  Hospital  should  be 
carried  through  essentially  as  they  are  at  present  worked  out  but  not  neces- 
sarily as  a  single  construction  undertaking.  There  is  good  reason  to  expect 
substantial  benefits  to  result  from  prosecuting  all  these  projects  at  the  same 
time,  if  the  relative  importance  of  the  several  undertakings  is  kept  continu- 
ously in  mind. 

Of  the  needs  of  the  University  Medical  School  and  of  the  needs  of  the 
community  for  hospital  beds  it  is  quite  clear  that  a  hospital  service  for  chil- 
dren of  all  ages  is  much  greater  than  is  the  need  for  beds  for  maternity  or 
for  general  medical  and  surgical  patients.  It  is,  therefore,  recommended 
that  as  soon  as  funds  can  be  provided  the  trustees  proceed  with  the  erection 
of  the  so-called  Babies'  Hospital  project,  which  it  is  understood  will  provide 
for  children  of  all  ages  to  a  total  of  150  beds.  The  next  in  the  order  of  im- 
portance, and  the  next  by  considerable  margin  of  importance  in  terms  of 
medical  teaching  or  community  need,  would  be  the  construction  of  a  Mater- 
nity Hospital  which  is  planned  for  100  beds.  In  approximately  the  same 
position,  but  perhaps  slightly  less  urgent  as  a  need  for  medical  education, 
though  obviously  needed  by  the  community  sooner  or  later,  is  the  erection 
of  the  new  Lakeside  Hospital.  As  soon  as  funds  can  be  provided,  therefore, 
should  come  the  construction  of  the  proposed  500-bed  hospital  for  general 
medical  and  surgical  patients,  including  a  pavilion  for  patients  with  mental 
and  nervous  disorders  for  the  department  of  psychiatry. 

Community  Relations 

Although  the  minimal  hospital  bed  needs  of  the  community  indicate 
that  Cleveland  will  require  the  additional  400  beds  which  the  University 
Group  project  would  provide  for  the  total  bed  capacity  of  Cleveland,  the  Sur- 
vey cannot  recommend  that  $12,000,000  be  spent  for  this  purpose  when 
medical  teaching  needs  do  not  demand  more  beds  and  when  that  number 
of  beds  could  be  provided  for  the  city  through  additions  to  other  hospitals 
at  a  half,  and  possibly  at  a  third,  of  this  expense,  if  built  solely  with  the  ob- 
ject of  providing  adequate  hospitalization  for  the  sick. 

Among  the  reasons  often  voiced  in  Cleveland  for  lack  of  full  professional 
and  public  trust  in  and  support  of  the  Medical  School  is  that,  under  the 
reasonable  argument  of  needs  for  clinical  teaching,  the  nomination  of  pro- 
fessional staffs  of  hospitals  is  permitted  by  the  trustees  of  certain  hospitals 
to  rest  with  the  faculty  of  the  Medical  School.  Whether  or  not  there  is  jus- 
tice in  this  criticism  it  is  apparent  that  no  asset  accrues  to  the  Medical  School 
if  it  is  in  a  position  of  exclusive  control  over  facilities  not  really  needed  for 
teaching  purposes.  It  is  suggested  that  any  formal  affiliations  with  hos- 
pitals except  those  now  maintained  at  the  City  Hospital  and  the  three  organi- 
zations of  the  University  Hospital  Group,  (Lakeside,  Maternity  and  Babies') 
be  severed,  unless  the  boards  of  trustees  of  the  hospitals  specifically  request 
the  University  through  its  medical  faculty  to  relieve  them  of  the  responsi- 
bility of  selecting  the  members  of  the  professional  staff  of  their  hospitals. 
Further  than  this  it  is  thought  that  the  funds  and  energies  of  the  Univer- 


656  Hospital  and  Health  Survey 

sity  and  its  teachers  should  not  be  devoted  to  operating  public  health  ser- 
vices such  as  a  city- wide  prenatal  and  maternity  service,  to  an  extent  greater 
than  is  needed  in  the  teaching  and  research  in  medicine.  To  demonstrate 
rather  than  to  operate  in  such  public  fields  would  seem  the  wiser  role. 

Another  matter  of  importance  to  the  University  in  its  relations  to  the 
public  is  its  contribution  of  part-time  service,  supervision,  and  direction  through 
members  of  its  teaching  staff  to  the  work  of  various  bureaus  of  the  Division 
of  Health.  It  is  thought  that  it  would  be  wiser  for  the  University  teachers 
to  be  held  in  an  advisory  capacity  rather  than  in  a  financial  relation  as  part- 
time  employes  of  the  city.  The  present  relationship  does  not  bring  credit  to 
the  University  although  the  services  are  of  a  grade  which  the  city  does  not 
seem  prepared  to  pay  for  at  their  true  value.  Any  criticism  of  the  public 
health  service  bears  back  upon  the  University  teachers  who  share  in  the 
responsibility  and  in  the  emoluments. 


Curriculum,  Instruction  and  Faculty  Organization 

Now  that  there  is  such  a  strong  and  increasingly  well-informed  Current 
of  public  opinion  in  matters  relating  to  preventive  medicine  and  health 
development  it  would  seem  a  particularly  propitious  time  for  the  University 
to  undertake  in  its  Medical  School,  education  of  its  medical  students  in  their 
responsibilities  to  the  public  as  quasi-health  officers,  as  private  practitioners 
and  as  students  of  the  broad  facts  of  epidemiology.  There  is  no  clinical 
subject,  major  or  minor  specialty,  which  is  not  susceptible  of  treatment  to 
the  end  that  preventive  as  wrell  as  diagnostic  and  therapeutic  objectives 
may  be  taught  in  each  patient.  Systematic  instruction  in  public  health 
problems  and  methods  is  now  an  obligation  of  every  medical  school,  which 
can  no  longer  be  escaped  on  the  plea  of  an  overcrowded  curriculum.  • 

In  proposing  that  industrial  hygiene  be  developed  as  a  department  of 
the  medical  school  or  better  as  a  separate  small  school  under  the  wing  of  the 
medical  school  the  particular  local  need  of  Cleveland's  employers  for  trained 
medical  officers  in  their  plants  and  the  great  variety  of  industrial  hazards 
not  at  present  adequately  studied  and  guarded  against  in  the  interest  of  the 
employes,  are  to  be  particularly  emphasized.  It  would  be  unwise  to  confuse 
the  training  of  industrial  physicians  with  the  training  of  physicians  for 
careers  as  public  health  administrators. 

Details  of  a  course  of  lectures,  demonstrations  and  laboratory  work 
have  been  given  to  the  members  of  the  medical  faculty  concerned,  by  the 
members  of  the  Survey  staff  in  charge  of  the  Industrial  Health  Survey. 

Special  reasons  for  urging  endowment  for  a  department  of  industrial 
hygiene  will  be  found  in  the  section  devoted  to  industry,  Part  VII.  Now: 
that  orthopedic  surgery  and  psychiatry  bid  fair  to  see  special  provision  made 
for  them,  there  remains  among  the  major  needs  a  special  opportunity  for 
urology  under  the  aegis  of  the  department  of  surgery. 


Professional  Education  and  Practice  657 

Generous  praise  must  be  given  for  the  quality  and  scope,  the  leadership 
and  product  of  the  laboratory  sciences  as  taught  by  the  medical  faculty. 

The  study  of  physiology  and  functional  pathology  is  well  coordinated  by 
special  teaching  in  clinical  study .a^  the  bedside. 


While  the  department  of  anatomy  has  ample  provision  for  staff  and  re- 
search and  is  particularly  favored  by  the  State  laws  under  which  a  collection 
of  material  of  very  great  value  has  been  obtained  in  the  course  of  many 
years  of  work,  the  fire  risk  of  the  present  unsuitable  quarters  gives  serious 
cause  for  anxiety.  It  is  certainly  unfortunate  that  the  teaching  of  em- 
bryology and  histology  are  not  as  well  coordinated  with  general  anatomy  as 
are  physiological  chemistry  and  general  physiology.  The  students  do  not 
at  i  present  get  the  best  that  the  teaching  staff  of  this  department 
and  the  modern  conception  of  anatomical  teaching  permit. 

Full-time  teaching  positions  for  the  head  of  the  main  clinical  depart- 
ments and  for  the  chief  assistants  in  clinical  instruction  are  much  to  be  de- 
sired and  would  be  welcomed  in  the  department  of  medicine  as  they  have 
been  established  in  the  department  of  pediatrics. 

Private  practice  ambitions  will  always  run  counter  to  the  best  tradi- 
tions and  quality  of  medical  teaching. . 

There  is  no  organization  of  clinical  departments  for  staff  conference, 
and  the  result  is  a  feeling  of  detachment  and  lack  of  interest,  particularly 
among  those  whose  teaching  never  comes  under  the  critical  and  stimulating 
eye  of  the  head  of  the  department.  Policies  and  standards  of  instruction 
where  there  are  several  hospital  services  used  for  teaching  can  only  be  put 
on  a  sound  basis  by  frequent  departmental  staff  conferences.  With  the  ex- 
ception of  the  departments  of  pathology  and  physiology  there  is  little,  if 
any,  contact  established  between  teaching  at  the  Medical  School  or  Lake- 
side and  the  teaching  at  City  Hospital. 

With  the  existing  active  executive  committee  of  the  medical  faculty  to 
relieve  that  body  of  the  burden  of  business  detail  and  to  be  ready  for  quick 
action  when  need  arises,  there  is  offered  an  excellent  opportunity  to  democ- 
ratize and  broaden  the  influence  of  the  faculty  and  of  the  forces  within  it, 
by  extending  membership  and  vote  to  a  larger  proportion  of  the  teaching 
staff.  It  is  of  great  importance  that  those  responsible  for  the  various  divi- 
sions of  teaching  meet  for  discussion  and  interchange  of  opinions  as  to  general 
policies  of  the  school.  Although  the  so-called  voting  faculty  of  24  might 
appear  to  give  a  broad  and  adequate  representation,  a  little  study  of  its' 
membership  shows  how  restricted  it  is.. 


658  Hospital  and  Health  Survey 

Medical  voting  faculty  consists  of: 

Votes  Members 

1 President  of  the  University . 

2 Senior  or  emeritus  professors,  inactive, 

not  teaching  or  in  touch  with  the 
college  work. 

1 Research   and   elective   teaching    pro- 
fessor only. 
20 Active  in  teaching. 

24 

Among  the  20  active  teachers  are  four  who  teach  less  than  thirty-five 
scheduled  hours  a  year.  One  associate  professor  in  a  clinical  specialty  has  a 
vote  but  has  no  clinic  and  teaches  only  16  hours  a  year. 

If  there  were  departmental  staff  organizations  so  that  the  head  of  a 
department  really  represented  his  department  with  full  knowledge  of  the 
opinions,  teaching  practices  and  so  forth,  of  his  colleagues  and  assistants, 
even  this  limited  group  (20)  would  give  a  good  working  representation,  but 
there  is  much  irrelevancy  in  the  assignment  of  voting  power  apparently,  for 
while  the  laboratory  subject  of  bio-chemistry  with  an  assistant  professor  is 
not  represented,  otology,  gynecology  and  genito-urinary  surgery  have  each 
a  vote. 

There  are  four  assistant  professors  who  teach  eighty  or  more  hours  each 
and  yet  have  no  voice  in  the  faculty;  not  that  representation  should  be 
based  on  the  hours  of  teaching  but  that  the  faculty  would  be  strengthened 
by  the  presence  of  men  who  are  devoting  so  much  of  their  lives  to  medical 
teaching,  men  whose  youth  and  ambition  is  now  rather  a  neglected  asset. 

The  danger  of  clique  domination  by  clinical  interests,  where  the  great 
resources  of  hospital  and  college  laboratories  for  private  advancement  are 
available,  is  always  to  be  feared  in  medical  schools,  and  to  meet  such  a 
possibility  prompt  democratization  of  the  voting  faculty  is  recommended. 

Lack  of  sufficient  junior  assistants  particularly  at  City  Hospital  forbids 
the  thorough  working  up  of  the  amazingly  fertile  material  in  clinical  medi- 
cine, surgery  and  pediatrics.  Diseases  of  metabolism,  tuberculosis,  cardiac 
disease  and  mental  diseases  appear  to  have  but  little  consideration  in  the 
general  plan  of  training  of  third  and  fourth  year  medical  students. 

The  teaching  of  surgery  at  Lakeside  is  almost  exclusively  carried  out 
by  the  paid  resident  house  officers,  the  head  of  the  department  confining  his 
field  to  demonstrations  and  operative  clinics.  The  surgery  taught  at  City 
and  at  St.  Vincent's  hospitals  is  not  brought  into  any  definite  or  constant 
relation  in  the  way  of  subject  matter  or  sequence  with  the  teaching  at  Lake- 
side.    There  is  generous  provision  for  research  in  both  surgery  and  medicine. 


Professional  Education  and  Practice  659 

The  teaching  of  obstetrics  and  of  pediatrics  in  the  fields  of  private 
practice  and  of  preventive  medicine  is  excellent.  The  department  of  pedia- 
trics lacks  adequate  dispensary  service  for  children  over  three.  The  de- 
partment of  obstetrics  has  more  material  than  it  needs  for  teaching  pur- 
poses. If  there  is  to  be  a  truly  modern  and  just  division  of  responsibility 
between  these  specialties,  the  new  born  babe  at  the  maternity  hospital  and 
in  the  homes  reached  by  the  out-patient  delivery  service,  should  be  turned 
over  at  once  to  the  care  of  the  pediatrists.  A  baby  should  not  be  an  ob- 
stetrician's responsibility  once  it  is  separated  from  the  mother,  and  the 
most  important  age  from  the  point  of  view  of  prevention  of  infant  mor- 
tality is  precisely  the  period  when  the  babe  is  now  under  the  care  of  the 
obstetrician. 

The  Medical  School  lacks  the  attention  and  service  for  organization, 
development  and  coordination  of  its  various  departments  and  functions 
which  are  primarily  the  duty  of  the  Dean  of  a  professional  school.  The 
reason  for  this  is  not  lack  of  understanding  or  appreciation  of  the  problems, 
but  the  overwhelming  occupation  of  the  Dean  in  an  absorbing  and  widely 
distributed  private  and  hospital  surgical  practice,  and  in  a  considerable 
amount  of  clinical  surgical  instruction  and  demonstration.  To  attempt  to 
maintain  adequate  direction  of  the  intricate  problems  of  the  Medical  School 
requires  more  time  and  undivided  attention  than  can  at  present  be  given  by 
the  Dean.  His  rare  and  invaluable  services  in  the  field  of  surgical  anatomy, 
pathology,  diagnosis  and  operative  treatment  can  ill  be  spared  or  his  organ- 
izing ability  be  demanded  at  the  expense  of  his  professional  career. 


History  of  the  College  and  the  Distribution  of  Its 
Graduates 

A  brief  summary  of  the  important  facts  about  the  Western  Reserve 
University  Medical  School  and  the  part  its  graduates  play  in  the  professional 
life  of  Cleveland  may  properly  be  included  here. 

Organized  in  1843  this  school  officially  joined  the  University  in  1881. 
In  1914  there  was  merged  with  the  Medical  School  of  Western  Reserve  Uni- 
versity the  Medical  Department  of  Ohio  Wesleyan  University  or  the  College 
of  Physicians  and  Surgeons,  itself  a  product  of  mergers  of  the  Charity  Hos- 
Hospital  Medical  College,  which  combined  with  the  Medical  Department  of 
Wooster  University  in  1870,  and  the  latter  institution  which  merged  with 
the  College  of  Physicians  and  Surgeons  in  1896. 

From  1814  to  1899,  the  Western  Reserve  University  School  of  Medicine 
graduated  1,085  physicians.  From  1900  to  1919  it  has  graduated  571  phy- 
sicians. There  graduated  in  1920,  45,  and  the  attendance  of  the  school 
during  the  academic  year  1919-1920  was  223,  divided  by  classes,  first  year 
49,  second  year  34,  third  year  41,  and  fourth  year  54.  It  is  the  policy  of 
the  school  to  limit  its  classes  to  fifty  students.  Laboratory  facilities  are 
inadequate  for  more. 


660  Hospital  and  Health  Survey 

The  number  of  the  teaching  staff  is  102  distributed  by  departments  as 
follows : 

Anatomy ..._ 8 

Biochemistry 2 

Physiology 3 

Pathology. 11 

Hygiene  and  Bacteriology 3 

Pharmacology  and  Therapeutics 4 

Medicine _. 23 

Pediatrics 9 

Surgery. _ 37 

Obstetrics  and  Gynecology 12 

112 

In  10  instances  teachers  hold  positions  in  two  departments.  At  Lake- 
side Hospital  forty  teachers  hold  staff  positions,  at  City  Hospital  twenty- 
three,  at  St.  Vincent's  Charity  Hospital  nine,  and  at  Maternity  Hospital 
four.  These  also  include  ten  duplications.  Forty  per  cent  of  the  clinical 
teachers  are  Western  Reserve  University  graduates. 

The  total  required  hours  of  work  in  the  present  four  year  course  at  the 
Western  Reserve  University  Medical  School  are  5,136  hours,  with  electives 
88  hours,  or  a  grand  total  of  5,224.  At  Northwestern  University  at  Chicago 
the  total  required  is  4,322  horn's.  At  the  University  of  Michigan  it  is  4,545 
hours,  and  at  Leland  Stanford  4,182  hours. 

The  following  table  shows  the  present  distribution  of  graduates  of^this 
school  in  the  practice  of  medicine  in  Cleveland. 

Western1"   Reserve    University   Graduates   Remaining   in   Cleveland 

Years-Group  No.  of  Graduates         No.  Practising  in  Cleveland  Per  Cent 

1860-79  596  16  2.67 

1880-89  523  38  7.26 

1890-99  297  72  24.2 

1900-09  239  90  37.6 

1910-14  128  57  44.5 

1915-19  204  58  28.4 


Total  1987  331  16.6 

Three  hundred  and  thirty-one  or  28.3%  of  1,169  physicians  in  Cleveland 
are  graduates  of  Western  Reserve  University  Medical  School.    Of  the  309 


Professional  Education  and  Practice 


661 


hospital  staff  positions  in  Cleveland,  75  or  24.2%  are  held  by  Western  Re- 
serve University  graduates  and  31  or  10%  by  Western  Reserve  University 
teachers,  graduates  of  other  schools,  or  a  total  of  34.2%  of  hospital  staff 
positions  held  by  Western  Reserve  University  graduates  and  teachers. 

The  following  three  tables  are  of  considerable  interest  to  teachers  and 
practitioners  of  medicine  in  Cleveland. 

TABLE  I* 
Medical  Department,  Western  Reserve  University,  Cleveland 


Year 

Estimated 
Popula- 
tion of 
City 

Classification 
by   Council   on 
Medical   Edu- 
cation 

3    "8 

W  £  V 

Z    « 

+-» 

CO 
3 

co 
u 
0 

Jffjffi 

u      .   , 

0<o 

TOTAL 

*■  •     "2  • 

FEES 

CO   >> 

■5c 

0 

5  co 
3.  v 
Zb> 

.S    CO 

C> 

jj   Ml 

£o 

Executive 
Officer 

1910 

506,938 

A 

94 

21 

18 

$130  $130  $130  $130 

84 

34 

F.C.Waite,  Sec . 

1911 

560,663 

A 

107-64 f 

14 

12 

142 

135 

135 

135 

114 

34 

a                a 

1912 

560,663 

A 

135-41 1 

35 

29 

142 

135 

135 

135 

89 

34 

a                a 

1913 

560,663 

A- 

144-1 7 f 

22 

21 

162 

155 

150 

155 

96 

34 

"                " 

1914 

560,663 

A- 

153-4f 

30 

30 

162 

153 

150 

155 

90 

33 

<t                it 

1915 

639,431 

A 

169 

38 

37 

162 

155 

150 

155 

93 

34 

tt                a 

1916 

656,975 

A 

178 

49 

49 

162 

155 

150 

155 

96 

34 

it                  a 

1917 

656,975 

A 

165 

32 

32 

175 

160 

154 

155 

107 

34 

C.A.Hamann, 

Dean 

1918 

674,073 

A 

181 

46 

46 

175 

160 

154 

155 

111 

34 

a             a 

1919 

674,073 

A 

180 

41 

41 

175 

160 

154 

155 

110 

34 

n             a 

*  The  statistics  were  taken  from  the  Educational  numbers  of  the  Journal  of  the  American  Medical 
Association,  1910,  through  1919. 

t  This  number  represents  students  of  Cleveland  College  of  Physicians  and  Surgeons  (absorbed  by 
Western  Reserve  University  in  1910)  who  received  instruction  at  Western  Reserve  and  degree  from  Ohio 
Wesleyan. 

TABLE  II*. 
Distribution  of  Medical  Students  at  Western  Reserve — By  States 


2    g  .2    g 
co  .5  -a    5 


co     3    co    .2?    v 


c  ■*    o 
«  co  > 


a  £    m 


a    co 


c  .6 

O     Ml 


<uuQE2S^^SS§§§S^    o    o 


U  Ml  •-     •£ 

5  .2    c  >    c   c 

rf     C     -2  o     Ml 

U  .       .UU-wU.3^^^0 

8  11. 1  ....  1  1   1 

8  1  112 

11  2  1 3  ..  2 

16  ..  ..   1   ..  2  3  12 

13  ....   1    1  3 4  ..  3 

13  11115  6  16 

10  12   116 5  ..  3 

8  ..  2  ....  3  -.  1  ...  3  ...  4 

9  ..  2  ..  ..  3  ..  1  1  4  ..  6 

11  ..  1  ....  7 5  13 


1910 


14  2  Ill 


1911  1  ..  1 3 

1912  1  ..  .. 3 

1913  11   2 


1914.. 

1915.. 

1916.. 

1917 

1918.. 

1919  1 


1  ..  1 

1  1  .. 

1  1  .. 

1  1  1 


5  1  1 

6  2  3 
5  1  2 
2  3  2 
2  2  2 

1  1  .. 

2  2.. 
4  2 

3  2 


..111 
..211 
111.. 

..  1  ..  .. 
..  1   ..  .. 


..  ..  1 
..  1  1 
..11 
1  1  1 
1    1   .. 


..  1 

..  1 

1  1 

1  1 


..     69  .. 

2   139  .. 

2   132  1 

1  114  2 

2  113  2 
2  121  1 
2  138  .. 
2   130  .. 


..  1   1   139 

..  ..   1   2   136 


94 
171 
176 
161 
157 
169 
178 
165 
181 
180 


'Copied  from  the  Journal  of  the  American  Medical  Association. 


662 


Hospital  and  Health  Survey 


TABLE  III.* 

Medical  College  Graduates 

Year 

Non- 
Sectarian 

Homeo 
pathic 

Eclectic 

Physio-         Nonde- 
Med.             script 

Total 

W.  R.  U. 

Grads. 

%of 
Total 

1910 

4,113 

183 

114 

16                 14 

4,440 

21 

.5 

1911 

4,006 

152 

110 

5 

4,273 

14 

.3 

1912 

4,206 

185 

92 

.... 

4,483 

35 

.8 

1913 

3,679 

209 

93 

.... 

3,981 

22 

.6 

1914 

3,370 

154 

70 

3,594 

30 

.8 

1915 

3,286 

195 

55 

.... 

3,536 

38 

1.0 

1916 

3,274 

166 

78 

.... 

3,518 

49 

1.3 

1917 

3,134 

180 

65 

.... 

3,379 

32 

.9 

1918 

2,454 

114 

42 

60 

2,670 

46 

1.7 

1919 

2,423 

89 

28 

116 

2,656 

41 

1.5 

*  Statistics  compiled  from  Table  VI.  page  502,  Journal  of  the  American    Medical  Association,  Aug.  16 
1919,  and  Educational  Numbers  of  Journal  of  the  American  Medical  Association,  1910  through  1919 

The  Western  Reserve  University  Medical  School  is  classed  as  A,  1907  to  1919,  by  the 
Council  on  Medical  Education  Of  the  American  Medical  Association. 


Instruction  for  Graduates 

An  important  service  undertaken  by  the  Medical  School  during  the  sum- 
mer of  1920  has  been  the  offering  of  systematic  instruction  to  medical  grad- 
uates in  clinical  medicine  and  surgery,  including  the  necessary  accessory 
training  in  anatomy,  pathology,  laboratory  aids  in  diagnosis,  and  such  co- 
operation from  teachers  in  various  specialties  as  is  necessary.  The  concep- 
tion of  the  program  is  broad,  the  spirit  of  the  teachers  is  of  the  finest  and  the 
fees  are  moderate,  and  there  may  be  expected  from  the  modest  beginning  of 
this  year  with  a  class  of  23,  such  steady  development  and  appreciation  of 
the  work  as  will  go  far  to  win  generous  professional  support  for  the  Medical 
School  and  its  ideals.  Once  endowment  is  provided  or  annual  support  is 
assured  for  the  teaching  of  medical  undergraduates,  there  should  be  a  public 
appeal  made  to  support  graduate  teaching  in  the  medical  sciences,  not  alone 
in  summer  but  as  a  necessary  service  for  the  University  to  provide  for  the 
profession  throughout  the  year.  Both  the  short  courses  in  diagnosis  and 
treatment  such  as  are  now  being  offered  and  courses  leading  to  the  proper 
training  of  specialists,  taking  one  or  two  years  of  combined  laboratory  and 
hospital  teaching,  are  urgently  needed  in  this  country. 


Professional  Education  and  Practice  663 

MEDICAL  PRACTICE 

Physicians  in  Cleveland  Classified  by  Specialty 

There  arejl,169  registered  physicians  in  Cleveland,  distributed  accord- 
ing to  their^own  statements  among  the  different  fields  of  practice  as  follows. 

General 878 

Surgery- 
Surgery  87 

Orthopedic  Surgery  4 91 

Internal  Medicine 1 6 

Tuberculosis 10 

Neurology  and  Psychiatry 

Neurology  3 

Psychiatry  2 

Neurology  and  Psychiatry  7 12 

Obstetrics  and  Gynecology 

Obstetrics  14 

Gynecology  12 

Obstetrics  and  Gynecology  4 30 

Pediatrics 23 

Ophthalmology,  Otology,    Laryngology  and   Rhinology 

Ophthalmology  12 

Ophthalmology  and  Otology  3 

Laryngology  and  Rhinology  4 

Otology,  Laryngology  and  Rhinology  21 

Ophthalmology,    Otology,    Laryngology    and 

Rhinology  15 55 

Laboratory  Specialties 

Pathology  1 

Clinical  Pathology  2 

Roentgenology  9 

Bacteriology  1 13 

Anesthesia 3 

Dermatology... 9 

Urology 11 

Public  Health 1 

Not  in  practice 14 

Retired 3 

1,169 


664  Hospital  and  Health  Survey 

Hospital  Staff  Service 

Estimating  the  number  of  internes  and  physicians  retired£or|not  prac- 
tising at  119  there  is  left  a  total  of  1,050  physicians  in  active  practice  (one 
to  every  758  of  the  population  of  Cleveland  in  1920).  Of  this  number  309 
or  29.4%  are  on  hospital  staffs. 

233  or  22.2%  are  on  the  staff  of  one  hospital. 
55    "    5.2 %   "     "       "      "     "  two  hospitals. 
15     "    1.4%  "     "       "      "     "  three        " 
5    "      .5%  "     "       "      "     "  four 
1    "      .09%  is  "       "      "     "  five  "  (as  pathologist). 

That  29.4%  of  all  the  practising  physicians  of  Cleveland  should  control 
the  opportunities  of  education  and  personal  advancement  afforded^by^80% 
of  the  hospital  beds  of  the  city  is  not  entirely  satisfactory. 

In  Boston  about  42%  of  the  practising  physicians  enjoy  hospita^oppor- 
tunities.  In  New  York  it  was  learned  from  a  recent  study  that  51.6%  of 
the  registered  physicians  have  hospital  or  dispensary  affiliations  (12.6%  only 
dispensary  affiliations,  12.8%  both  hospital  and  dispensary  affiliationsjand 
26.2%  only  hospital  affiliations). 

Of  545  physicians  who  have  served  as  internes  in  Cleveland  hospitals 
chiefly  within  the  past  ten  years,  196  or  36%  are  now  practising  in  Cleve- 
land. These  graduates  who  represent  the  best  product  of  our  present 
methods  of  medical  education  should  be  attached  as  soon  as  possible  after 
leaving  their  hospital  to  some  hospital  service,  at  first  in  the  dispensary  or 
as  assistants  in  the  laboratory,  but  with  a  definite  future  of  clinical  oppor- 
tunity open  to  them  through  merit  and  the  willingness  to  sacrifice  some 
immediate  financial  gains  for  the  sake  of  a  higher  professional  training. 

Professional  Organizations 

Professional  organization  in  Cleveland  resembles  that  of  other  large 
cities  and  has  provided  the  resources  in  the  shape  of  library  and  meetings 
which  are  a  necessity  in  a  rapidly  developing  profession  and  one  in  which 
criticism  by  one's  fellows  and  discussion  of  results  and  scientific  reports  play 
so  important  a  part. 

Cleveland  Academy  of  Medicine 

Previous  to  1902  there  were  two  medical  societies  in  Cleveland:  the 
Cleveland  Medical  Society  and  The  Cuyahoga  County  Medical  Society. 
In  1902  the  Cleveland  Academy  of  Medicine  was  formed  by  the  union  of 
the  two  societies  mentioned  above.  The  Academy  membership  is  approxi- 
mately 600.  The  general  meetings  are  held  once  a  month  on  the  third 
Friday  of  the  month  in  the  auditorium  of  the  Cleveland  Medical  Library 
Association.  The  Clinical  and  Pathological  section  meets  on  the  first,  and 
the  Experimental  medicine  section  on  the  second  Friday  in  the  month. 
The  Eye,  Ear,  Nose  and  Throat  Section  has  not  met  for  some  years.     The 


Professional  Education  and  Practice  665 

Academy  is  the  county  medical  society  and  is  the  local  constituent  unit  of 
the  Ohio  State  Medical  Association  and  of  the  American  Medical  Associa- 
tion. 

Recently  a  more  aggressive  spirit  has  come  over  the  Academy  and  with 
the  services  of  full-time  lay  assistance,  the  officers  have  undertaken  the  pub- 
lication of  a  bulletin  and  have  declared  their  intention  to  interest  themselves 
and  the  rest  of  the  profession  in  the  modern  problems  of  health  insurance 
and  legislation  of  various  kinds  affecting  the  professional  and  economic  status 
of  physicians  in  Ohio. 

The  responsibility  for  the  deplorable  conditions  which  exist  practically 
unchecked  among  the  foreign  born  population,  due  to  the  exploitation 
of  the  sick  and  the  well  by  quacks  and  patent  medicine  interests,  rests  to 
some  degree  if  not  chiefly  with  the  indifference  of  the  organized  medical 
profession.  The  attention  of  the  officers  of  the  Academy  of  Medicine  is 
called  to  the  report  on  Quacks  and  Patent  Medicines  in  Relation  to  the 
Foreign  Born  of  Cleveland,  which  follows  at  the  end  of  this  chapter. 

Cleveland  Medical  Library  Association 

In  1894  the  Cleveland  Medical  Library  Association  was  formed.  Pre- 
vious to  this  time  a  considerable  number  of  books,  purchased  from  funds 
contributed  by  the  County  Medical  Society,  had  been  gathered  in  Case 
Library.  In  1895  a  contract  was  entered  into  with  Case  Library.  The 
Library  set  aside  space  for  the  Association  books  and  agreed  to  care  for  and 
bind  them  and,  if  reimbursed  for  the  amount  expended  for  binding,  to  de- 
liver the  books  to  the  Association  upon  demand.  In  1898,  on  account  of 
lack  of  space,  it  was  necessary  for  the  Library  to  terminate  this  arrange- 
ment. After  due  deliberation  the  property  now  occupied  by  the  Library  at 
2318  Prospect  Avenue  was  purchased  by  the  Association.  In  1906  a  fire- 
proof stack-room  and  auditorium  were  added.  In  1919  the  property  adjoin- 
ing on  the  west  was  purchased. 

The  Cleveland  Medical  Library  Association  is  incorporated  under  the 
Ohio  laws.  The  management  of  its  business  affairs  is  in  the  hands  of  a  Board 
of  Trustees,  who  act  through  an  Executive  Committee.  The  traditional 
policy  is  the  re-election  of  officers  to  ensure  continuity  of  policy  and  con- 
servation in  the  handling  of  funds.  The  working  librarian  serves  on  a  full- 
time  basis.  The  hours  are  9:30  A.  M.  to  10  P.  M.  To  the  general  public 
are  extended  reading  privileges.  Only  members  are  permitted  to  withdraw 
books. 

According  to  the  Librarian's  report  for  1919  the  total  number  of  volumes 
is  24,312.  847  books  were  loaned  during  the  year  and  1,853  visitors  to  the 
Library  were  registered.     The  Library  receives  166  different  journals. 

The  Library  is  supported  by  the  dues  of  its  members — about  260  in 
number — and  the  income  of  invested  funds,  the  total  of  the  funds  being 
somewhat  over  $270,000.  The  funds  are  handled  largely  by  two  trust 
companies. 


666  Hospital  and  Health  Survey 

The  Library  is  restrained  from  combining  with  any  other  society  or 
organization  by  terms  of  the  Allen  gift,  the  principal  of  which  is  $200,000. 

.  The  Library  which  has  capacity  for  doubling  its  present  contents  is  used 
to  only  a  small  fraction  of  the  needs  of  the  profession.  That  less  than  six 
readers  a  day  visited  the  Library  and  less  than  one  book  was  borrowed  for 
each  medical  practitioner  of  the  city  in  1919,  is  a  commentary  upon  the 
acquisitiveness  of  the  physicians  in  the  field  of  modern  medicine,  and  reflects 
also  a  lack  of  adequate  advertisement  and  propaganda  by  the  Library  Asso- 
ciation itself  of  its  own  resources. 

The  policies  of  the  Library  are  liberal  and  its  financial  support  sufficient 
to  meet  many  more  needs  for  medical  references  than  seem  to  be  felt  by  the 
profession  in  Cleveland. 

The  Cleveland  Medical  Journal. 

The  publication  of  the  Cleveland  Medical  Journal  was  discontinued 
during  the  war  and  has  not  as  yet  been  resumed.  While  the  Journal  was  the 
official  organ  of  the  Academy  it  had  no  other  relation  with  the  Academy 
and  was  owned  and  published  by  a  separate  corporation  as  a  public-spirited 
enterprise,  not  for  profit.  The  Academy  contributed  to  the  Journal,  each 
year,  $2.00  per  member.  There  seems  to  be  no  urgent  need  for  the  resump- 
tion of  this  journal  at  a  time  when  every  economy  must  be  practised  to  per- 
mit the  survival  of  those  which  serve  a  wider  audience  and  offer  space  for 
most  of  the  important  contributions  to  medical  science. 

Private  Medical  Organizations 

There  are  several  private  medical  organizations  serving  to  some  degree 
social  and  scientific  needs  of  the  profession.  Among  these  are  the  Cleveland 
Homeopathic  Medical  Society  which  was  organized  in  1865  (there  are  at  present 
about  150  members),  the  Cleveland  Colored  Medical  Society  organized 
in  1916  (30  members,  18  of  whom  are  doctors,  8  dentists  and  4  pharmacists), 
and  the  Cleveland  Public  Health  Association,  a  branch  of  the  American 
Public  Health  Association,  organized  May  21,  1919  (the  membership  is  45, 
and  is  limited  to  those  who  are  members  of  the  national  organization). 

Professional  Opportunities 

The  medical  profession  has  suffered  severely  in  its  development  in 
Cleveland  by  reason  of  the  serious  shortage  of  hospital  beds.  Visiting  ser- 
vices which  will  be  needed  when  the  necessary  increment  of  beds  is  added 
to  existing  hospital  capacities  should  provide  openings  for  most  of  the  pro- 
fession willing  and  trained  to  give  a  high  grade  of  service  in  hospitals. 

There  is  lacking  in  Cleveland  that  unity  of  spirit  among  the  physicians 
which  comes  from  a  just  distribution  of  equal  opportunities  and  from  generous 
support,  encouragement  and  advancement  of  the  young  and  ambitious  by 
their  seniors. 


Professional  Education  and  Practice  667 

A  better  trained  group  or  with  higher  professional  ideals  would  be  hard 
to  find  than  the  recent  graduates  of  the  local  medical  school.  They  are 
entitled  to  a  quicker  recognition,  particularly  those  who  have  dedicated 
themselves  to  various  of  the  special  fields  of  laboratory  and  clinical  prac- 
tice, lines  of  effort  not  sufficiently  appreciated  in  Cleveland. 

According  to  information  obtained  from  those  chiefly  concerned 
with  general  medical  practice  and  consultation  work  in  internal  medicine, 
there  is  a  very  unusual  indifference  among  Cleveland  physicians  to  the 
value  of  laboratory  tests  in  confirmation  of  diagnosis  or  as  checks  upon 
clinical  impressions  and  physical  findings  in  the  cause  of  disease.  The  use 
of  the  tests  in  medical  practice  now  available  in  the  fields  of  blood  chemistry 
and  immunology  is  practically  unknown  in  Cleveland. 

Autopsies 

A  comment  which  could  not  fail  to  come  to  the  lips  of  any  visiting- 
physician,  particularly  from  European  medical  teaching  centers,  would 
certainly  be  that  the  use  of  the  autopsy  is  not  appreciated  as,  at  the  same 
time,  the  most  valuable  postgraduate  education  for  hospital  physicians  and 
surgeons,  and  the  cause  of  a  respectful  humility  among  teachers  and  students 
alike  in  the  presence  of  the  secrets  of  disease. 

During  1919  there  were  recorded  455  autopsies  in  the  hospitals  of  Cleve- 
land, and  it  is  fairly  clear  that  autopsies  are  rarely  performed  outside  of 
hospitals  on  private  patients  and  about  as  rarely,  in  the  honest  meaning  of 
the  term,  under  the  auspices  of  the  Coroner's  office. 

Of  the  455  recorded  autopsies  it  will  be  seen  from  the  following  list 
that  351  were  performed  in  the  hospitals  where  medical  teaching  is  carried 
on:  namely,  at  City,  Lakeside,  St.  Vincent's  and  Maternity. 

Autopsies   Performed   in   Cleveland   Hospitals   in   1919 

City 209  approximately 

Fairview 0 

Glenville 1  or  2 

Grace _ unknown 

Huron  Road 5 

Lakeside... 110 

Lutheran 0 

Maternity. 8 

Mount  Sinai 50 

Provident 0 

St.  Alexis unknown 

St.  Ann's. 20  orphanage  children 

St.  Clair... 1 

St.  John's 20 

St.  Luke's 5 

St.  Vincent's 27 

Woman's 0 

Lakewood a  few 

455 


668 


Hospital  and  Health  Survey 


Even  at  the  hospitals  where  post-mortem  study  is  urged  and  has  its  best 
chance  in  Cleveland  the  percentage  of  deaths  which  come  to  autopsy  is  piti- 
fully small  as  can  be  seen  from  the  following  list. 


Year 

1914 
1915 
1916 
1917 
1918 
1919 


Year 

1917 
1918 
1919 


Lakeside  Hospital 

Deaths  Autopsies 


Percentage 


226 

85 

38 

243 

107 

44 

284 

114 

40 

273 

97 

35 

350 

64 

18 

317 

City  Hospital 

110 

37 

Deaths 

Autopsies 

Percer 

1,168 

156 

13 

1,211 

202 

17 

863 

207 

24 

Year 

1916 
1917 
1918 
1919 


5f.  Vincent's  Hospital 

Deaths  Autopsies 

131  16 


182 
178 
331 


18 
21 
16 


Percentage 

12 
10 
12 

5 


The  pathologists  of  the  hospitals  are  well  aware  of  the  neglect  of  the 
post-mortem  as  an  invaluable  educative  resource,  but  interest  is  rarely  as 
keen  among  the  surgeons  and  physicians  on  duty. 

Public  Health  administration  and  the  practice  of  curative  medicine  alike 
would  be  gainers  if  a  post-mortem  examination  were  required, in  every  death 
occurring  in  the  hospitals  of  the  city.  It  is  distinctly  a  duty  of  the  Hospital 
.Council  to  take  a  definite  stand  in  this  matter,  see  that  hospital  superin- 
tendents feel  their  responsibility  for  obtaining  consent  for  autopsies  from 
the  family  or  friends  of  the  deceased  and  apply  this  necessary  control  obser- 
vation to  the  clinical  and  operative  services  of  the  attending  staff. 

No  better  statement  as  to  the  action  it  is  desirable  to  take  can  be  found 
than  the  following  quotation  from  the  writings  of  the  leading  pathologist  of 
Cleveland. 


Professional  Education  and  Practice  669 

"Investigations  of  the  cause  of  the  general  shortcoming  of  American  medicine  in 
studying  the  accuracy  of  clinical  diagnosis  lead  to  a  variety  of  explanations  and  an  equal 
variety  of  suggestions  for  improvement.     The  latter  may  be  thus  summarized: 

There  should  be: 

1.  Education  of  the  public  as  to  the  importance  of  post-mortem  ex- 
aminations to  public  health. 

2.  Improvement  of  legislation:  (a)  obviation  of  the  necessity  for 
written  permission  to  perform  a  necropsy,  and  (b)  recognition  of  the  differ- 
ence between  anatomic  dissection  and  the  necropsy. 

3.  Improvement  of  hospital  regulations. 

4.  Increased  development  of  the  interest  of  physicians  in  the  necropsy. 

5.  Encouragement  of  the  selfish  interest  in  post-mortems  on  the  part 
of  intelligent  relatives  of  the  dead. 

6.  Assignment,  in  large  hospitals,  of  certain  persons  whose  special 
duty  it  shall  be  to  secure  permission  for  post-mortem  examinations. 

7.  Information  given  the  family  as  to  the  conditions  disclosed  by  the 
necropsy. 

8.  A  request  for  necropsy  in  every  fatal  case  in  hospital  or  private 
practice. 

9.  Establishment  in  the  hospitals  of  regular  clinical  pathologic  con- 
ferences. 

We  would  suggest,  in  addition,  that  the  subject  is  of  direct  importance  to  the  devel- 
opment of  industrial  medicine  and  that  those  interesting  themselves  in  this  subject  point 
out  to  the  employers  and  employes  the  value  to  medicine  and  industry  of  post-mortem 
examinations.  The  suggested  alteration  of  actuarial  figures  regarding  life  insurance  is  of 
similar  importance  to  the  so-called  health  insurance." 


RECOMMENDA  TIONS 

It  is  recommended  that: 

1.  New  trustees  who  are  still  in  the  midst  of  the  actual  problems  of  industry,  of  the 
professions  and  of  public  service,  be  added  to  the  present  number  of  trustees  or  be  ap- 
pointed when  the  terms  of  those  trustees  now  serving  expire. 

2.  One  or  more  trustees,  chosen  by  the  alumni  of  the  Medical  School  from  their 
own  number,  be  elected  to  the  Board. 

3.  Medical  School  buildings  be  erected  at  a  site  which  will  permit  of  convenient 
contact  between  the  medical  faculty  and  the  faculties  of  the  other  University  schools. 

4.  In  addition  to  its  control  of  the  exceptionally  abundant  facilities  of  the  City  Hos- 
pital for  the  teaching  of  clinical  medicine  to  undergraduates,  the  University  Medical 
School  maintain  such   affiliations  as  it  now  has  with  Lakeside,  Maternity  and  Babies' 


670  Hospital  and  Health  Survey 


Hospital,  permitting  medical  research  and  study  in  methods  of  teaching  which  can  hardly 
be  carried  out  with  such  entire  liberty  in  an  institution  of  the  public  nature  of  City  Hospi- 
tal, where  political  and  financial  difficulties  may  interfere  occasionally  with  the  best  inter- 
ests of  scientific  medical  teaching  and  study. 

5.  The  trustees  discontinue  formal  affiliations  for  the  Medical  School  with  other 
hospitals  than  the  City  Hospital  and  the  three  included  in  the  University  group,  so  far  as 
systematic  teaching  activities  are  concerned. 

6.  At  the  same  time  that  the  project  for  Medical  School  buildings  is  undertaken 
the  trustees  prepare  a  plan  for  financial  support,  either  by  endowment  or  through  annual 
pledges,  which  will  adequately  provide  for  the  salaries  of  the  teachers  and  the  maintenance 
and  service  needs  of  each  department  of  the  Medical  School. 

7.  The  trustees  of  the  University  devote  their  best  efforts  to  obtain  such  changes 
in  the  City  Charter  as  may  be  found  practicable  and  such  action  from  the  officers  of  the 
city  government  as  may  be  necessary  to  insure  the  appointment  of  a  board  of  trustees  to 
be  responsible  for  the  administration  of  the  City  Hospital,  such  trustees  to  be  selected 
from  representative  groups  of  citizens  by  the  Mayor  and  to  be  appointed  by  him. 

8.  The  building  of  the  new  hospital  group,  either  as  one  construction  undertaking 
(if  ample  funds  are  available)  or  in  sequence  (in  the  following  order  of  preference — Babies' 
Hospital,  Maternity  Hospital  and  Lakeside  Hospital)  be  commenced  when  the  construction 
of  Medical  School  buildings,  the  provision  of  endowment  or  adequate  annual  support  for 
teaching  and  the  removal  of  City  Hospital  from  the  probability  of  political  mismanagement 
have  been  assured,  or  at  least  have  been  so  planned  for  that  their  accomplishment  will 
parallel,  if  not  precede,  the  group  hospital  construction. 

9.  Neither  funds  nor  the  energies  of  University  teachers  or  institutions  be  devoted 
to  the  operation  of  public  facilities  and  medical  services,  except  in  so  far  as  these  can  be  made 
to  contribute  or  are  found  necessary  for  the  teaching  and  study  of  the  medical  sciences. 

10.  The  University  discourage  the  employment  of  its  officers  on  a  part-time  basis 
in  positions  under  the  city  government. 

1 1 .  Systematic  instruction  in  the  problems  and  principles  of  preventive  medicine  be 
included  in  the  curriculum  of  undergraduate  students  without  necessarily  adding  a  new 
department  or  increasing  the  number  of  hours  of  instruction  now  given  to  medical  stu- 
dents. 

12.  A  department  for  the  training  of  physicians  in  the  field  of  industrial  medicine 
be  established  as  soon  as  adequate  funds  can  be  provided,  this  department  and  its  func- 
tions not  to  be  confused  with  such  efforts  as  the  University  may  undertake  for  the  train- 
ing of  physicians  and  others  for  the  career  of  public  health  administrators. 

13.  The  trustees  push  forward  vigorously  with  the  present  plans  for  a  department 
of  orthopedics,  under  the  general  department  of  surgery,  but  free  to  develop  its  own  teach- 
ing and  research  policies,  with  clinical  facilities  independent  of  those  of  general  surgery. 

14.  A  department  of  psychiatry  with  a  similar  independence  under  the  general 
department  of  medicine  be  organized  and  provided  with  independent  clinical  facilities. 

15.  A  department  of  urology  be  added  to  the  independent  special  departments 
under  the  department  of  surgery. 


Professional  Education  and  Practice  671 


16.  The  extension  of  the  principle  of  full-time  teaching  positions  for  the  heads  of 
the  main  clinical  departments  and  for  the  chief  assistants  be  undertaken  as  soon  as  salaries 
can  be  assured,  adequate  to  attract  trained  teachers  and  to  permit  of  their  having  ample 
time  for  research. 

17.  The  medical  faculty  adopt  the  policy  of  having  staff  conferences  in  each  depart- 
ment to  provide  for  uniform  teaching  policies  and  practice  in  the  various  clinical  hospital 
services  used  by  these  departments. 

18.  The  voting  faculty  of  the  Medical  School  drop  its  inactive  and  absentee  members 
and  add  not  less  than  ten  more  members  of  the  teaching  staff,  assistant  professors,  demon- 
strators and  others,  in  order  to  make  of  this  body  a  real  academic  forum,  democratic  in 
nature,  and  permitting  a  much  broader  representation  from  those  carrying  the  major 
burden  of  the  teaching  work. 

19.  To  the  Department  of  Pediatrics  be  assigned  the  responsibility  and  care  for 
new-born  babies  at  the  Maternity  Hospital  and  in  the  maternity  service  of  the  City  Hos- 
pital. 

20.  The  trustees  of  the  University  encourage  and  give  their  active  support  to  the 
new  undertaking  of  the  medical  faculty  in  the  field  of  medical  education  for  graduate 
physicians. 

21.  The  Hospital  Council  take  an  active  interest  in  increasing  the  performance  of 
post-mortem  examinations  for  the  sake  of  improving  the  quality  of  medical  and  surgical 
services  in  the  hospitals. 


672  Hospital  and  Health  Survey 

Quacks  and  Patent  Medicines 

By  Mary  Strong  Burns 

THERE  are  many  perils  in  being  an  immigrant  in  Cleveland,  but  one 
of  the  most  disastrous  to  his  pocket,  health  and  native  faith  is  the 
quack  medical  practitioner.  With  an  estimated  .513,000  of  the  city's 
731,1.56  population  either  of  foreign  birth  or  foreign  parentage  in  1917,  we 
have  abundant  opportunity  to  realize  that  it  is  not  possible  for  the  foreign- 
born  with  limited  education  and  no  English  to  pass  unscathed  through  a 
labyrinth  of  new  customs — good,  bad  and  indifferent. 

The  doctor,  as  popularly  conceived  by  the  uneducated,  is  a  mystery  at 
best,  something  of  a  magician  from  whom  the  patient  dares  expect  only  a 
small  part  of  the  truth  and  no  explanation  of  it.  The  immigrant  learns 
that  the  reputable  doctor  of  medicine  must  have  "M.  D."  after  his  name  (even 
though  it  means  as  little  to  the  immigrant  as  to  the  street  gamin  who  "guessed 
it  meant  More  Dope"),  and  when  he  pauses  before  an  office  door  placarded 
"M,  T.  D.,  D.  C,  D.  S.  T.,  Ph.  C."  he  may  be  forgiven  for  imagining  that 
he  stands  before  an  even  greater  "Professor"  than  the  law  requires.  He 
finds  as  wide  a  choice  of  doctors  as  of  religions,  and  as  he  hesitates,  bewildered, 
the  more  watchful  and  aggressive  forces  find  him. 

Of  these  the  quack  doctors  are  most  successful  because  they  set  forth  in 
that  particular  foreign  language  newspaper  which  the  immigrant  reads  as 
the  one  intelligible  guide  to  his  new  country,  a  convincing  statement  of  skill, 
learning  and  sympathy,  promising  (with  reservations  so  deftly  inserted  as 
to  be  almost  unnoticeable)  health  free  or  at  minimum  cost.  Even  though 
the  immigrant  feels  well  and  in  no  need  of  medical  care  the  quack's  repeated 
message  and  the  long  list  of  "troubles  and  diseases"  is  ever  present  and 
suggestive,  so  that  the  susceptible  imagination  of  the  future  victim  is  soon 
won  over  to  a  conviction  of  some  bodily  frailty.  The  quack,  at  the  first 
examination,  finds  more  serious  ailments,  the  "cure"  of  which  will  generally 
necessitate  an  expenditure  to  the  limit  of  the  patient's  resources  and  large 
enough  to  include  the  high  cost  of  advertising. 

The  foreign  language  newspapers  derive  from  30  per  cent  to  60  percent 
of  their  advertising  income  from  the  fraudulent  statements  of  quack  prac- 
titioners and  patent  medicine  interests.  It  has  been  conservatively  esti- 
mated that  the  Italian  paper  II  Progresso  and  the  Polish  paper  Ameryka 
Echo  circulated  here  derive  60  per  cent  of  their  income  from  these  sources. 
In  one  of  these,  one  advertisement  of  "Parto-Glory, "  containing  723  words, 
cost  about  $1L2.5. 

There  are  twenty-one  newspapers  not  printed  in  English  circulated  in 
Cleveland,  published  locally.  These  are  mostly  papers  of  national  circula- 
tion. There  are  also  eleven  foreign  language  papers.  Taking  all  together, 
twelve  different  languages  are  used:  Bohemian,  German,  Greek,  Hungarian, 
Italian,  Lithuanian,  Polish,  Roumanian,  Slovak,  Slovenian,  Swedish  and 
Ukrainian.     The  papers  published  here,  with  the  exception  of  three,  carry 


Professional  Education  and  Practice  673 

only  advertisements  of  physicians  and  medical  agencies  doing  business  from 
a  Cleveland  office,  and  nearly  one-third  of  their  advertising  income  is  derived 
from  this  source.  The  papers  published  out  of  town  but  circulated  in  Cleve- 
land are:  four  published  in  New  York  and  one  each  in  Chicago,  Detroit, 
Jersey  City,  Middletown,  Pa.;  Pittsburgh,  and  Toledo.  These  do  not  con- 
tain advertisements  of  Cleveland  quacks,  although  they  are  not  limited  to 
local  advertising.  They  do,  however,  contain  advertisements  of  62  quack 
doctors  from  other  cities,  and  of  these  only  two  from  Detroit  are  duplicated 
in  the  list  of  out-of-town  quacks  who  advertise  in  the  foreign  language  papers 
published  in  Cleveland. 

Of  the  25  physicians  having  offices  in  town  and  advertising  in  the  Cleve- 
land foreign  language  newspapers,  one  uses  papers  in  six  languages,  one,  four 
languages,  three,  two  languages  and  twenty,  one  language.  Thirteen  of  these 
physicians  advertise  only  their  address  and  office  hours.  This  is  an  admit- 
tedly ethical  and  legitimate  procedure  among  foreigners.  The  doctor  may 
thus  announce  his  presence  to  people  of  his  own  race.  Because  of  this  prece- 
dent the  quack  practitioner  may  use  a  more  elaborate  form  without  arousing- 
suspicion,  the  foreign-born  reader  often  getting  the  idea  that  the  newspaper 
itself  is  setting  forth  the  doctor's  skill  and  goodness.  Thus  eight  of  the 
twenty-five  physicians  advertised  to  treat  at  their  offices  "all  sicknesses  of 
men  and  women,  especially  sicknesses  of  the  blood,  heart,  kidneys,  lungs, 
nerves,  nose  and  throat;"  two  treat  "blood  and  skin  diseases,"  and  two 
others  treat  "men  only,"  evading  a  more  open  reference  to  venereal  disease. 

In  this  class  is  the  type  of  office  whose  apparent  head,  the  quack  doctor, 
is  under  the  control  of  an  unscrupulous  business  syndicate.  This  syndicate 
manages  offices  in  a  number  of  large  cities,  guaranteeing  salaries  and  a  cer- 
tain percentage  to  the  doctor  in  charge,  but  claiming  the  fees  of  the  patients. 
In  one  of  these  offices  in  Cleveland  when  business  was  interrupted  by  arrest, 
the  receipts  for  the  year  were  found  to  have  amounted  to  $40,000.  If  illegal 
practice  is  detected  the  business  manager  of  the  syndicate  appears,  pays  the 
fines,  closes  the  office  and  spirits  his  doctor  away  to  an  office  in  another  city 
where  a  new  name  and  locality  will  make  him  more  valuable  than  ever. 
After  the  affair  has  slipped  out  of  the  public  mind,  the  syndicate  opens  its 
Cleveland  office  at  a  different  address  and  in  charge  of  a  new  agent  and  the 
game  begins  again.  The  agent  of  the  syndicate  may  or  may  not  be  a  licensed 
practitioner.  He  may  have  had  his  license  revoked  in  another  state.  In 
any  case  his  medical  knowledge  is  less  in  demand  than  his  skill  at  getting  a 
cash  return  for  any  imitation  of  it.  If  a  license  is  necessary  to  avoid  sus- 
picion and  the  agent  does  not  possess  one,  some  unsuccessful,  though  once 
ethical,  practitioner  is  lured  into  the  game  on  the  promise  of  a  small  regular 
salary,  and  when  the  crash  comes  he  is  usually  left  to  be  the  scapegoat  and 
serve  the  sentence. 

The  eight  out-of-town  physicians  advertising  in  foreign  language  papers 
published  in  Cleveland  have  offices  as  follows:  one  in  Akron,  one  in  Chicago, 
three  in  Detroit,  one  in  Paterson,  N.  J.;  one  in  Syracuse,  N.  Y.  A  private 
clinic  in  New  York  advertises  in  a  German  paper.  The  Hungarian  paper 
published  the  notices  of  the  Paterson  and  Syracuse  doctors  and  of  two  from 


674  Hospital  and  Health  Survey 

Detroit;  the  Roumanian  those  of  Akron  and  Chicago  doctors,  and  one  from 
Detroit.  The  advertisements  of  these  out-of-town  physicians  show  that  five 
would  treat  "all  troubles,"  one  will  treat  "men  only,"  one  "rheumatism 
and  kidney  troubles,"  and  one  chronic  diseases.  One  states  that  he  will 
send  medicines  and  advice;  one  offers  a  book,  The  Friend  of  Youth;  one  de- 
clares "Hundreds  travel  to  see  me,  no  treatment  through  letters;"  another 
invites,  "(Jome,  or  ask  advice." 

The  appeal  of  the  quack  is  effectively  adapted  to  the  susceptible  foreign 
temperament.  In  the  picturesque  phraseology  of  his  own  tongue  the  reader 
is  tempted,  cajoled,  lured,  warned  and  roused  to  fear;  trading  on  his  natural 
credulity,  the  wording  of  the  advertisement  is  carefully  managed  so  as  to 
imply,  rather  than  guarantee,  a  cure.  The  appeal  of  money  saving  is  most 
frequent.  "My  advice  is  free;"  "I  will  help  you  with  the  best  medical  care 
for  such  price  as  you  can  pay;"  "I  do  not  charge  for  examination  if  you  are 
one  of  my  patients;"  "X-Ray  examinations  only  $1;"  "Pay  after  you  are 
cured."  This  type  of  appeal  is  in  constant  use.  Other  types  are  here  set 
down. 

The  appeal  of  encouragement:  "No  matter  what  illness  you  have  if  you 
have  failed  to  find  health  from  others,  come  to  me;"  "With  success  I  have 
cured  many.  What  I  have  done  for  others  I  can  do  for  you;"  "Men  and 
women  my  specialty." 

The  appeal  of  fear,  urging  to  prompt  action:  "Remember  that  neglect- 
ing your  trouble  makes  it  worse;"  "I  have  saved  hundreds  from  the  operating 
table." 

The  appeal  through  promise  of  a  common  language:  "You  can  hold 
conversation  with  me  in  your  own  tongue;"  "Come  to  me  and  be  well 
informed  about  your  sickness  and  understand  how  you  can  be  cured;" 
"Here  we  speak  Hungarian;"    "We  speak  Polish,"  etc. 

The  appeal  of  race:  One  florid  description  of  sundry  abilities  is  headed: 
"To  my  sick  Roumanian  Brothers;"  "To  my  sick  Lithuanian  Brothers" — 
the  nationality  mentioned  changing  with  the  language  of  the  paper.  Another 
who  still  practises  in  spite  of  past  fines  and  sentences  uses  this  subtle  method, 
"A  message  to  the  Italians.  Sick  Italians,  do  not  be  discouraged.  Thou- 
sands of  our  countrymen  have  found  health  and  happiness  by  going  to  see 
Dr.  Landis.     His  treatments  are  simply  marvelous!" 

The  appeal  of  special  skill  and  "method  cures":  "I  use  X-Ray  and 
electrical  machines  and  my  own  new  methods  of  treatment.  By  these 
methods  you  will  recover  health  in  the  quickest  possible  time;"  "To  save 
the  stomach  my  practice  is  to  inject  the  medicine  directly  into  the  arteries, 
which  hastens  considerably  the  process  of  restoring  to  health." 

The  appeal  to  the  imagination:  "Formerly  doctor  to  the  Czar;"  "A 
Polish  doctor  returned  from  U.  S.  Army  Service  in  France.  Come  and 
place  your  confidence  in  me." 


Professional  Education  and  Practice  675 


The  appeal  to  sentiment:  "If  you  are  well  yourself,  yet  there  are  some 
who  need  help.  Send  us  the  names  of  others  who  are  sick  and  save  them 
while  there  is  a  chance." 

The  type  of  appeal  is  more  vivid  and  dramatic  in  Italian,  Polish  and  Hun- 
garian papers;  while  that  in  Swedish,  Lithuanian  and  German  is  more  matter- 
of-fact. 

No  fake  advertising  was  found  in  the  Greek  paper,  Atlantis. 

In  addition  to  the  appeal  of  the  quack,  the  foreign  language  press  abounds 
in  advertisements  of  patent,  or  more  properly,  proprietary  medicines  offered 
by  "medical  institutes,"  "medical  companies,"  drug  manufacturers  and 
retail  drug  stores.  These  usually  claim  in  the  newspapers  to  be  remarkable 
cures  for  almost  every  disease  that  one  may  have,  while  the  label  on  the 
bottle  is  more  modest  since  that  must  conform  to  the  food  and  drug  act. 
This  act,  known  as  the  "Pure  Food  Law,"  is  supposed  by  many  to  be  a  seal 
of  perfection,  whereas  it  merely  insists  that  the  manufacturer  shall  make 
no  false  or  misleading  statement  on  the  label  of  the  bottle  as  to  its  contents 
or  curative  power.  It  does  not  affect  products  made  and  sold  within  the 
state.  It  prohibits  the  use  of  certain  dangerous  drugs  unless  their  presence 
is  declared,  yet  allows  other  dangerous  drugs  to  be  used  and  not  declared. 
While  the  label  must  tell  the  truth  the  advertiser  need  not  be  so  punctilious 
and  in  his  hands  the  patent  medicine  takes  on  new  power§.  Some  of  the 
advertisements  ask  the  patient  to  send  by  mail  to  the  factory  for  medicine. 
Others  would  send  medicine  and  instructions  for  treatment  by  mail.  Still 
others  announce  that  their  product  may  be  bought  anywhere.  The  Roman 
Medicine  Company  announces,  "Our  institution  is  under  the  supervision  of 
well-known  medics  from  the  old  country.  It  was  established  to  relieve  our 
countrymen  of  their  sufferings.  Aher  years  of  labor  and  research  we  dis- 
covered what  is  indispensable  to  cure  our  brothers  of  their  sickness.  Put  a 
cross  (X)  on  the  illness  from  which  you  are  suffering  and  send  it  to  us.  We 
will  serve  you  free  of  charge  with  every  necessity."  Here  follows  a  tempting 
array  of  "troubles,"  minor  ailments  and  pains.     One  has  only  to  choose. 

In  addition  to  these  perils  by  newspaper  there  are  also  perils  by  propa- 
ganda. Cards  of  reputable  physicians  have  been  sent  out  with  prescrip- 
tions by  retail  druggists  who  implied  that  the  doctor  was  also  endorsing  the 
sample  of  patent  medicine  enclosed.  Recently  a  young  woman,  whose  dress 
and  manner  suggested  that  of  a  public  health  nurse,  was  found  visiting  in 
the  homes  of  women  with  families.  She  came  ostensibly  to  advise  them  on 
the  care  of  children  and  ended  by  selling  a  book  in  which  patent  medicines 
from  several  large  wholesale  houses  were  repeatedly  recommended  for  treat- 
ment. These  wholesale  manufacturers  of  patent  medicines  employ  clever 
lawyers  at  high  salaries  to  protect  their  interests.  If  the  preparation  comes 
into  disrepute  under  one  name  it  may  be  used  under  another.  Tan-lac  has 
had  several  names.  As  a  Dr.  Cooper's  Medical  Discovery  it  was  sold  by  a 
man  in  sky-blue  uniform  with  buttons  of  five-dollar  gold  pieces,  who  drove 
through  the  country  in  an  automobile. 


676  .      Hospital  and  Health  Survey 

The  Ohio  State  Medical  Board  is  the  instrument  upon  which  Cleveland 
has  relied  for  the  detection  of  its  quacks.  There  is  only  one  state  medical 
inspector  for  a  city  of  nearly  800,000  people.  This  is  obviously  too  great  a 
task  for  one  person.  The  State  Medical  Board  publishes  no  report  except 
for  the  Governor  and  the  Secretary  of  State,  on  July  1st  of  each  year.  The 
following  statement  was  submitted  to  us  by  the  Board: 

From  July  1,  1918,  to  June  30,  1919,  certificates  of  four  physicians 
and  surgeons  to  practise  medicine  were  revoked ;  one  certificate  suspended 
and  certificate  of  one  limited  practitioner  revoked;  nine  applications  for 
revocation  are  pending;  8  midwives  were  prosecuted  and  convicted;  one 
acquitted. 

One  hundred  and  sixty-three  cases  investigated;  28  convictions  secured; 
3  cases  acquitted. 

There  were  two  dismissals  and  one  disagreement. 

Fifteen  against  whom  charges  were  filed  agreed  to  cease  practice. 

Fifteen  more  left  the  state. 

Forty  cases  were  pending  on  June  30,  1919;  a  number  of  these  pending 
cases  have  since  been  tried  and  conviction  secured. 

The  state  medical  inspector  for  the  city  offered  an  informal  account  of 
her  work,  all  records  having  been  sent  to  Columbus  as  made,  to  await  the 
compiling  of  the  annual  report  in  July.  There  have  been  a  number  of  con- 
victions of  doctors  and  midwives  for  illegal  practice  and  criminal  abortion, 
and  other  cases  are  being  prosecuted.  The  work  is  evidently  being  done 
conscientiously  and  is  as  far-reaching  as  the  efforts  of  one  inspector  can 
reasonably  make  it.  However,  a  judicious  and  wider  publicity  of  the  ac- 
complishment of  the  State  Medical  Board  might  be  of  distinct  educational 
value  in  the  community.  The  patient  victimized  by  the  quack  does  not 
realize  that  his  plight  is  the  concern  of  anyone  other  than  himself. 

It  is  difficult  to  state  how  large  a  number  of  Cleveland  patients  are  treated 
through  the  mails  by  out-of-town  quacks,  but  as  practically  every  fraudulent 
scheme  depends  upon  the  mails  at  some  time  or  other  in  its  development, 
we  are  safe  in  believing  that  the  Federal  Authorities  have  not  received 
complaints  from  all  those  who  have  been  defrauded. 

The  Federal  Fraud  Order  Law,  in  use  since  1914,  gives  the  Post  Office 
Department  authority  to  close  the  mails  to  anyone  using  the  mails  in  schemes 
to  defraud.  This  may  be  an  enormously  effective  weapon  against  quacks 
doing  a  large  mail-order  business.  The  post  office  collects  evidence  enough 
to  be  sure  of  conviction,  then  issues  the  Fraud  Order.  The  quack,  if  he  has 
not  already  vanished,  has  a  right  to  refer  to  the  court,  but  a  reversed  judg- 
ment has  never  been  recorded.  In  a  word,  the  Federal  Post  Office  will 
only  attempt  cases  wrhich  it  is  sure  of  convicting.  This  law  is  also  sharply 
limited  because  the  Post  Office  Department  cannot  move  until  the  mails 
have  been  actually  used  in  an  attempt  to  commit  fraud.  It  must  wait  until 
it  receives  a  complaint  from  someone  who  has  been  defrauded. 


Professional  Education  and  Practice  677 

The  quack  advertiser  has  purposely  shaped  his  proposition  to  come  within 
the  letter  of  the  law  and  to  so  avoid  the  attention  of  the  Federal  eye  as  long  as 
possible.  He  knows  his  own  danger  and  at  the  first  symptom  of  detection 
collects  his  bounty  and  "skips  the  country,"  leaving  the  evidence  powerless 
to  convict  and  his  victims  without  redress. 

The  Fraud  Order  Law  has  proved"  a  radical  cure  for  the  cases  in  which  it 
has  been  utilized,  but  the  number  of  these  is  small.  Its  scope  should  be 
enlarged  and  its  scheme  of  inspection  made  to  include  those  who  advertise 
with  intention  to  defraud,  for  in  this  matter  prevention  is  both  education 
and  cure.  The  value  of  this  law  depends  largely  not  on  its  passive  acceptance 
but  on  its  aggressive  enforcement.  The  patient  who  has  been  the  victim 
should  not  be  expected  to  make  the  complaint.  There  should  be  some 
unbiassed  agency  or  group  of  agencies  combining  the  knowledge  of  the  Bureau 
of  Immigration,  State  Medical  Board  and  National  Vigilance  Committee  of 
Advertising  Clubs  to  receive  the  complaint  and  present  the  case  to  the 
Federal  Authorities.  Such  an  agency  or  bureau  possibly  and  properly  oper- 
ating under  the  auspices  of  the  Cleveland  Academy  of  Medicine,  could  be  of 
untold  benefit  to  the  many  cases  of  venereal  disease  who  have  so  often  be- 
come the  prey  of  quack  practitioners  through  lack  of  sufficient  provision  for 
treatment  at  hospitals  and  dispensaries.  It  could  also  furnish  evidence  of 
the  need  of  further  legislation  to  restrict  the  use  of  the  mails  from  carrying 
advertisements  relating  to  venereal  disease. 

The  American  Medical  Association  has  prepared  and  published  a  series 
of  pamphlets  on  nostrums  and  quackery  for  the  use  of  the  public.  These 
have  a  limited  circulation  among  those  who  least  need  their  warning.  With 
discriminating  field  work  this  circulation  could  be  increased.  The  priest, 
whose  congregations  have  had  sad  experiences,  the  large  industrial  plants 
and  their  public  health  nurses,  the  libraries  and  popular  magazines  could  be 
used  to  good  effect.  The  emphasis  in  such  education  might  be  placed  first 
upon  the  hallmarks  of  honest,  intelligent  treatment  of  disease,  and  second 
upon  the  fact  that  each  one  must  stop — look — listen  and  then  think  for  him- 
self before  he  trusts. 

Assuming  the  theory  that  the  Acidemy  of  Medicine  must  not  take  any 
action  on  quack  behavior,  we  might  urge  that  dispensaries  and  prophylactic 
centers  should  feel  free  to  teach  as  well  as  to  practise  the  ethics  of  medical 
service,  supplementing  the  mysteries  of  diagnosis  and  technic  with  a  pro- 
gram of  cheerful  consideration  for  the  patient  and  of  eliminating  the  diffi- 
culty of  an  alien  language  by  sympathetic  and  patient  interpreters  who  are 
not  too  highly  intellectualized  to  miss  the  human  side  in  the  medical  interest 
of  a  case. 

The  Americanization  Committee  of  the  Cleveland  Bar  Association  has 
already  become  interested  in  the  dealings  of  shyster  lawyers  with  the  foreign- 
born.  This  interest  could  be  stimulated  to  secure  valuable  cooperation  from 
the  court  when  quack  practitioners  are  being  prosecuted  and  defended  with 
unprincipled  skill  by  their  shyster  lawyers. 


678  Hospital  and  Health  Survey 

The  foreign-language  newspapers  cannot  afford  to  give  up  their  bad  types 
of  advertising  unless  they  can  get  something  equally  remunerative  to  replace 
it.  One  small  foreign-language  paper  refused  quack  and  patent-medicine 
advertising  to  an  amount  of  $1,500  a  month  because  its  people  were  being 
exploited  and  victimized.  As  a  result  it  could  barely  pay  expenses,  but  the 
editor  declared  he  "felt  at  peace  without  stained  money."  It  has,  however, 
gradually  resumed  much  of  what  it  once  refused — an  instance  of  "the  heroic 
for  earth  too  hard." 

The  American  Association  of  Foreign -Language  Newspapers  was  recently 
reorganized  under  the  leadership  of  well  known  business  men,  one  of  its 
stated  purposes  being  to  improve  the  advertising  in  the  foreign-language 
press  of  this  country.  They  are  pointing  out  to  American  advertisers  the 
possibilities  of  the  foreign-language  paper  as  a  medium  for  reaching  new 
readers.  In  conjunction  with  the  Better  Business  Association  of  the  Cleve- 
land Advertising  Club,  this  may  be  of  assistance,  providing  the  foreign- 
language  papers  do  not  have  to  surrender  the  control  of  their  individual 
policy.  The  large  foreign-born  population  is  too  valuable  a  field  to  be 
neglected  by  advertisers.  The  foreign-language  press  might  offer  to  the 
future  citizen  the  stimulus  of  the  best  the  country  affords  of  resources  and 
responsibilities.       At  present  its  misuse  amounts  to  almost  a  civic  disaster. 

Should  we  be  better  satisfied  to  receive  the  immigrant  who  comes  to  our  shores 
suspicious,  distrustful,  prepared  to  be  duped  and  tricked  both  by  Americans 
and  fellow  countrymen — who  have  had  a  chance  to  learn  the  ways  of 
the  country?  Can  we  not  look  upon  this  "ignorance,  gullibility,  child-like 
credulity,"  or  whatever  we  call  his  eager  belief  and  wonder  at  our  world, as 
something  worth  saving,  precious  because  readily  convertible  into  citizen- 
ship as  loyal  and  even  more  fervid  and  spontaneous  than  our  native  New 
Englander,  Texan  or  Rocky  Mountaineer  will  feel  free  to  express. 

The  quack  has  conquered  where  the  ethical  practitioner  has  failed  to 
attract,  because  the  quack  has  taken  the  "infinite  pains"  of  a  genius  to  win 
his  prey.  As  commercialist  and  practical  psychologist  he  is  an  expert.  The 
clean  honesty  of  the  ethical  practitioner  is  not  equally  painstaking.  It 
should  not  be  asked  of  the  ethical  practitioner  that  he  cope  with  quackery, 
but  because  he  is  pledged  as  his  "brother's  keeper,"  shall  he  not  note  in  the 
successful  appeal  of  the  quack  to  his  patient  the  things  which  are  promised 
along  with  the  cure — friendly  consideration  as  a  stranger,  a  sympathetic 
hearing  and  a  frank  diagnosis  explained  so  as  to  be  understood?  These  are 
of  value  whether  the  cure  comes  or  not,  for  to  the  imaginative  foreign  tem- 
perament a  serious  illness  sympathetically  interpreted  by  the  doctor  is  less  ap- 
palling than  some  trivial  indisposition  left  unexplained.  Is  it  not  possible 
to  have  some  more  flexible  attitude  on  the  part  of  the  medical  profession 
and  some  more  aggressive  attitude  for  ourselves  as  the  public  in  the  matter? 
Our  health  regulations  no  longer  permit  people  to  expose  themselves  un- 
necessarily to  contagion.  Is  the  menace  of  quackery  to  be  ignored?  We 
see  in  our  midst  a  multitude  of  people  from  other  worlds  being  fed  with  tales 
in  their  native  tongue  of  fake  cures  by  fake  operators.  We  watch  and  think 
"It  will  be  bitter  bread  for  them."     The  doctors  watch  and  think  "It  is  all 


Professional  Education  and  Practice  679 

wrong  but  we  may  not  speak."  The  foreign-language  newspaper  counts  its 
advertising  cash  returns  and  prints  on,  thinking  "The  National  Vigilance 
Committee  of  the  Associated  Advertising  Clubs  of  the  World  allows  it,  the 
city  of  Cleveland  allows  it,  the  public  does  nothing,  the  income  justifies  it." 

Only  the  future  warns:  "The  immigrant's  instinct  for  belief  in  his  new 
country  is  a  tremendous  asset  to  the  nation  and  to  the  city  of  his  choice. 
The  opportunity  of  justifying  this  belief  and  for  providing  education  and 
citizenship  is  open  to  the  foreign  language  newspaper.  It  is  the  written 
word,  the  organ  of  authority,  but  those  who  control  its  policy  are  in  turn 
controlled  by  larger  business  interests  and  these  are  prostituting  its  high 
office  for  commercial  gain.     Let  the  city  waken  and  protect  its  right." 

Translations  of  Advertisements  Shown  in  Facsimile  on  Page  680 

1.  'TO  MY  SICK  HUNGARIAN  BROTHERS* 

If  you  have  failed  to  find  help,  come  to  me,  as  I  have  practised  many  years  and  can 
give  health  with  treatments  to  such  men  and  women  as  are  nervous  or  ill  with  complicated 
sickness,  suffering  because  someone  has  given  the  wrong  treatment  or  neglected  it.  With 
success  I  have  cured  such  sick  who  could  not  get  cured  elsewhere.  What  I  have  done  with 
others,  I  can  do  with  you.     Don't  spend  more  time  but  come  to  me  today.     Advice  free. 

If  you  suffer  with  chronic  nervousness,  blood,  skin,  or  complicated  trouble,  or  abdomen, 
stomach  and  liver  trouble,  rheumatism,  back  or  muscles,  headache,  constipation,  dizziness, 
eruptions,  disease  of  the  head,  throat,  nose — visit  me.  I  have  succeeded  with  such  sick- 
nesses by  treatment.  Respectfully  I  will  give  you  my  opinion  and  after  a  good  examina- 
tion will  tell  you  what  I  can  do.  Get  advice  from  me  now  as  waiting  is  often  dangerous. 
Don't  forget  that  advice  is  free. 

Office  hours  from  9  a.  m.  to  8  p.  m. — Sunday  from  10  a.  m.  to  2  p.  m. 

Dr.  Kenealy, 
647  Euclid  Ave.,  2nd  Floor,  Cleveland,  Ohio. 
Over  New  Idea  Bakery  Republic  Building  Next  Door  Star  Theater" 

•Translation  of  advertisement  in  Hungarian  published  in  Szabadsag. 

2.  "CHRONIC  AND  NERVE  DISEASES  CURED* 

If  you  are  afflicted  with  an  upset  stomach  or  kidneys  or  bladder,  consult  me  today. 
Seek  help  where  it  can  be  found.  Years  of  experience  in  the  treatment  of  all  nervous  ail- 
ments, either  chronic  or  complicated,  have  enabled  me  to  give  you  scientific  electrical  treat- 
ments that  will  help  you  in  cases  where  other  methods  have  failed,  and  therefore  many  have 
been-  freed  from  torture  and  danger  of  an  operation.  Remember:  that  delay  and  improper 
treatments  are  dangerous.  Come  to  me  if  you  wish  to  have  the  services  of. an  expert 
specialist. 

Dr.  Lewis,  Specialist 
Office  hours:  9  a.  m.  to  8  p.  m. — Sundays  10  a.  m.  to  2  p.  m. 
749  Sixth  Avenue  (between  42nd  and  43rd  Streets),  New  York  City." 
•Translation       advertisement  in  Italian  published  in  II  Progresso 


Professional  Education  and  Practice  ^  681 

3.  "A  MESSAGE  TO  THE  ITALIANS!* 

Sick  Italians,  do  not  be  discouraged  if  you  have  not  been  able  to  obtain  the  desired 
cure  even  after  having  been  visited  by  different  doctors,  or  been  in  many  hospitals. 

Hundreds,  or  rather  thousands,  of  our  countrymen  have  found  health  and  happiness 
by  going  to  see  Dr.  Landis.  Dr.  Landis  with  his  25  years  of  practice  in  New  York,  having 
studied  in  the  greatest  universities  and  hospitals  of  America  and  Europe,  is  just  the  man 
who  will  put  you  on  the  road  to  health.  His  treatments  are  really  wonderful.  His  office 
is  equipped  with  the  most  costly  electrical  machinery,  which  cannot  be  found  at  all  doctors' 
offices  and  which  is  indispensable  for  an  efficient  cure. 

Dr.  Landis  has  experimented  with  a  method  cure  of  electricity  which  has  given  wonder- 
ful results  and  which  allows  individuals  to  get  well  without  having  to  leave  their  work. 

If  you  suffer  with  pains  in  your  back,  or  rheumatism,  or  sickness  of  the  chest  or  blad- 
der, with  weakness  or  anemia  or  any  other  illness,  be  it  chronic  or  recent,  consult  Dr. 
Landis  and  you  will  certainly  find  a  sure  cure.  All  consultations  are  absolutely  free. 
Remember  that  in  any  sickness  to  wait  is  always  dangerous.  Why  wait?  Go  this  very 
day.      Italian  is  spoken. 

Dr.  Leonardo  Landis,  140  East  22nd  Street,  New  York  City. 

(Between  3rd  and  Lexington  Aves.) 

Office  hours:  Every  day  from  10  a.  m.  to  7  p.  m.     Sunday  from  10  a.  m.  to  1  p.  m." 

"Translation  of  advertisement  in  Italian  published  in   II  Progresso. 


4. 


"X-Ray  examination  $1.00.* 


If  you  are  sick,  notwithstanding  what  the  nature  of  your  sickness  is,  if  you  are  dis- 
couraged, do  not  give  up  hope  but  come  to  me. 

I  treat  all  sicknesses  of  men  and  women  and  especially  sicknesses  of  the  blood,  skin, 
stomach,  kidneys,  lungs,  nerves,  heart,  nose  and  throat  by  the  assistance  of  X-Ray  and 
electrical  machines  and  my  new  methods  of  treatments.  By  these  methods  you  will  recover 
your  health  in  the  quickest  possible  time. 

I  do  not  guess.  The  secret  of  my  success  lies  in  the  careful  research  as  to  the  cause  of 
your  sickness.  I  use  X-Ray,  microscope  and  chemical  analysis  and  also  all  learned  meth- 
ods to  find  the  cause  of  the  sickness. 

If  you  are  bruised  or  injured,  come  to  me  and  I  will  help  you. 

My  personal  observation  of  the  methods  used  in  European  clinics  in  Berlin,  London, 
Vienna,  Paris  and  Rome  in  my  20  years'  experience  with  sicknesses  that  have  grown  old 
among  men  and  women,  gave  me  results  that  proved  a  success. 

I  consider  605  and  914  great  medicines  for  the  blood. 

All  treatments  are  absolutely  painless. 

"Translation  of  advertisement  in  Polish  published  in  Polonea  W.  Ameryce. 


682  Hospital  and  Health  Survey 

You  can  depend  on  an  honest  opinion,  honest  treatment,  and  the  best  treatments 
at  the  lowest  prices  that  everyone  can  afford. 

If  your  sickness  cannot  be  cured  I  will  tell  you.  If  it  can  be  cured  I  will  cure  it  in  the 
quickest  possible  time. 

We  talk  in  Polish  and  Slovak. 

Doctor  Bailey,  Specialist,  5511  Euclid  Avenue,  near  East  55th  Street. 

Office  hours  9:30  a.  m.  to  8  p.  m." 

RECOMMEND  A  TIONS 

1.  Legislation: 

(a)  A  more  aggressive  use  and  increased  scope  of  the  Federal  Fraud  Order  Law. 

(b)  A  uniform  Medical  Practice  Act  between  states,  to  be  urged  by  the  Cleveland 
Academy  of  Medicine. 

2.  Administration: 

(a)  A  Local  Bureau  organized  to  receive  and  act  on  complaints  of  medical  fraud. 
This  Bureau  would  make  known  its  function  to  the  public  and  to  all  Public  Health  agencies, 
who  in  turn  would  report  such  cases. 

(b)  Increased  Inspection  and  prosecution  by  the  State  Medical  Board. 

(c)  Development  of  the  Americanization  Committee  of  the  Cleveland  Bar  Associa- 
tion for  cooperation  in  prosecution. 

3.  Education: 

(a)  Extended  instruction  in  the  ethics  of  medical  service  among  medical  students, 
and  also  to  patients  in  hospitals,  dispensaries,  health  centers  etc. 

(b)  General  health  education  in  popular  courses  (in  a  foreign  language  when  neces- 
sary) in  citizenship  classes,  industrial  plants,  churches,  community  centers  etc. 

4.  Standardization  of  Foreign-Language  Press: 

Fraudulent  advertising  to  be  replaced  by  advertising  and  general  reading  matter  of 
good  standard,  through  the  assistance  and  supervision  of  the  Chamber  of  Commerce,  the 
Cleveland  Advertising  Club  and  other  civic  bodies,  for  the  protection  and  education  of 
the  foreign-born  during  his  transition  from  immigrant  to  citizen. 

5.  Counteraction: 

Giving  all  would-be  patients  first-aid  treatment  of  psychology  and  self-control. 

Democratizing  the  highest  types  of  medical  service  so  that  the  best  shall  be  available 
for  all. 


Professional  Education  and  Practice  683 

Dentistry  in  Cleveland 

By  Haven  Emerson,  M.  D. 

ASIDE  from  or  rather  in  addition  to  the  persistent  forces  which  tend  to 
drive  any  profession  onward  and  upward  in  public  esteem,  the  dental 
profession  in  this  country  has  been  advanced  in  its  own  cone  ?pt ion  of 
service  and  in  its  scientific  application  of  prevention  and  treatment  of  dis- 
ease by  two  movements  of  much  importance.  The  demonstration  of  the 
benefits  of  oral  hygiene  and  periodic  cleansing  of  the  teeth  of  children  by 
Dr.  Fones,  of  Bridgeport,  Conn.,  and  the  proof  of  casual  relationship  between 
focal  infection  in  root  canals  and  other  dental  lesions  and  a  multitude  of 
secondary  joint,  cardiac  and  general  constitutional  symptoms  may  be  said 
to  have  dominated  much  of  the  modern  crusade  for  better  dentistry,  for 
preventive  dentistry  and  for  the  close  professional  cooperation  between 
dentistry  and  medicine  in  private,  hospital  and  public  health  work. 

In  all  of  this  Cleveland  dentists  have  taken  an  active  and  leading  part 
and  the  city  is  fortunate  in  having  within  its  limits  those  who  direct  the  for- 
tunes of  the  Dental  College,  the  Research  Laboratory,  the  Cleveland  Dental 
Society  and  the  Cleveland  Mouth  Hygiene  Association. 

According  to  the  best  information  there  are  about  550  registered  dentists 
in  Cleveland,  of  whom  290  are  members  of  the  Cleveland  Dental  Society, 
which  is  the  local  professional  body,  a  constituent  of  the  state  and  national 
dental  societies. 

If  the  Ohio  Dental  Practice  Act  required  an  annual  registration  of  all 
dentists,  as  is  the  case  in  several  other  states,  an  accurate  statement  of  the 
number  of  dentists  legally  practising  dentistry  in  Cleveland  could  be  made. 
The  better  control  of  illegal  practice  which  such  law  permits  has  proved  to 
be  of  great  value  to  the  profession  and  to  the  public,  in  New  York  State 
among  others. 

The  private  practice  of  dentistry  in  Cleveland  presents  no  abuses  or 
inadequacies  except  such  as  arise  from  the  selfishness  and  ignorance  of  an 
occasional  practitioner  who  fails  to  measure  up  to  the  present  day  standards 
of  his  profession.  The  well-to-do  and  those  of  moderate  means  can  obtain 
adequate  dental  care  without  excessive  expense  and  of  a  high  grade  whether 
for  preventive  or  reparative  purposes. 

From  the  reports  of  the  highest  type  of  supervising  dental  officers  in  the 
army  during  the  war,  it  was  found  that  well  over  75%  of  the  crown  and 
bridge  and  root  canal  filling  was  done  so  poorly  as  to  develop  or  permit  the 
development  of  pus  pockets  with  all  the  dangers  of  secondary  low  grade 
sepsis  and  its  numerous  sequelae.  Mechanical  dentistry,  done  for  a  price 
instead  of  aseptic  technic  used  in  the  spirit  of  modern  surgical  science, 
seems  to  be  at  least  as  much  of  a  cause  of  disease  as  the  neglect  of  oral  and 
dental  hygiene  by  the  poor  and  ignorant. 

There  are  quacks  and  commercial  low  grade  practitioners  in  this  as  in 
the  medical  profession,  because  there  is  often  more  money  in  such  methods 


684  Hospital  and  Health  Survey 

for  the  illegitimate  and  irresponsible  than  in  a  professionally  conducted  office. 
The  Jews  of  the  Woodland  Avenue  region  suffer  particularly  from  the 
services  of  dental  quacks. 

Free  dental  work  in  Cleveland  is  supplied  at  six  public  schools,  at  three 
health  centers  and  at  one  hospital  (City  Hospital).  There  are  ten  chairs  in 
use  and  156  clinic  hours  a  week,  or  a  totalof  6,900  hours  a  year  of  service 
offered.  The  work  is  mostly  for  children  and  for  hospital  out-patients.  A 
dental  dispensary  used  for  teaching  purposes,  operating  80  chairs,  is  main- 
tained on  a  more  than  self-supporting  basis  by  the  Dental  College.  The 
fees  charged  are  similar  to  those  charged  by  beginning  dental  practitioners. 

In  Boston  five  institutions  offer  either  free  or  at-cost.  dental  services 
with  a  total  of  247  chairs  used  for  5,956  hours  a  week  and  309,712  hours  a 
year.  In  the  city  of  Rochester,  N.  Y.,  there  are  38  chairs  almost  exclusively 
for  children's  work. 

The  six  school  dental  dispensaries  are  supported  by  the  taxpayer's  money 
through  the  Board  of  Education.  Each  unit  includes  a  dentist  and  an 
assistant  and  is  open  five  days  a  week  for  three  hours  at  each  session  and  for 
40  weeks  a  year.  Children  are  referred  from  among  school  children  by  the 
school  medical  inspectors  and  nurses.  The  extent  to  which  the  work  has 
grown  and  the  range  of  service  given  is  seen  in  the  following  table: 


Patients 

Visits... 

Emergency — 

Prophylaxis. -. 

Amalgam.... ... 

Deciduous  extraction... 

Permanent  extraction.... — 

Surgery  referred. ~ 

Oxyphosphate  of  copper. 

Oxyphosphate  of  zinc 

Arsenic 

Roots  filled 

Abscess  treatment.. 

The  three  mouth  hygiene  dispensaries  operated  by  the  Cleveland  Mouth 
Hygiene  Association  at  three  of  the  health  centers  are  operated  for  fifty  weeks 
of  the  year,  five  days  a  week  and  three  hours  at  each  session.  The  outfit 
and  personnel  of  each  is  the  same  as  that  provided  for  the  school  dental 
clinics.  The  cost  of  these  is  met  from 'the  Community  Fund  as  a  part  of  the 
budget  presented  by  the  Welfare  Federation. 

A  dental  surgery  open  a  half  day  (of  three  hours)  a  week  for  out-patients 
needing  operative  relief  and  extractions,  and  six  half  days  (of  three  hours 


17  Total 

1918  Total 

1919  Total 

1,969 

3,473 

4,421 

4,454 

'  6,411 

6 ,  976 

651 

1,267 

1,621 

383 

661 

1,196 

839 

1,654 

3,165 

1,608 

1,927 

3,911 

142 

56 

18 

192 

15 

183 

127 

670 

1,399 

112 

115 

61 

126 

61 

5 

188 

87 

5 

109 

136 

67 

Professional  Education  and  Practice  685 

each)  a  week  for  the  hospital  patients  is  provided  by  the  city  at  City  Hos- 
pital.* 

At  the  College  of  Dentistry  of  Western  Reserve  University"  a  public  den- 
tal clinic  is  operated  for  all  kinds  of  dental  work.  This  is  more  than  sup- 
ported by  the  charges  made,  which  are  not  very  different  from  charges  of 
beginning  practitioners  with  a  clientele  of  mechanics,  clerks  and  small  trades 
people.  The  lack  of  adequate  bookkeeping  prevents  any  statement  of  the 
margin  of  profit  earned  by  this  dental  dispensary.  The  profit  of  $24,000 
indicated  in  the  last  annual  report  of  the  University  is  obviously  erroneous 
as  nothing  is  charged  for  building  or  upkeep,  depreciation,  light,  heat  and 
so  forth  or  for  the  overhead  cost  of  teachers  and  supervisors. 

Self-supporting  public  pay  clinics,  operated  under  strict  professional  con- 
trol as  to  services  and  prices,  are  needed  and  would  meet  a  real  demand  for 
those  of  moderate  means. 

Dental  care  for  the  poor  is  limited  largely  to  extraction  and  remedy 
of  gross  pathological  conditions  causing  obvious  inconvenience  or  pain.  Lack 
of  knowledge  of  the  needs  and  possibilities  of  oral  hygiene  is  responsible  for 
the  neglected  teeth  of  most  dispensary  patients.  Dental  clinics  where  a 
small  fee  is  charged  are  badly  needed  in  the  congested  districts. 

It  is  admitted  that  if  all  who  needed  dental  care  applied  to  existing  den- 
tists for  treatment,  there  would  not  be  enough  dentists  to  do  the  work  on  a 
basis  and  with  the  facilities  of  private  practice. 

The  three  Mouth  Hygiene  dispensaries,  operated  five  half  days  per  week, 
are  the  only  available  and  acceptable  service  (except  the  private  dental 
practitioner)  for  thirty  to  thirty-five  thousand  parochial  school  children. 
Fifteen  Mouth  Hygiene  units,  each  composed  of  a  dentist,  a  dental  hygienist 
and  an  assistant,  operated  eleven  half  days  per  week,  would  serve  this  group 
of  children  quite  well;  i.  e.,  would  provide  the  prophylactic  service  neces- 
sary for  eighty-five  or  ninety  per  cent  of  these  children  and  would  provide 
for  from  one-third  to  one-half  of  the  repair  service  necessary. 

The  public  schools  of  Cleveland  should  increase  their  present  equipment 
from  six  dispensaries  operated  five  half  days  per  week  to  thirty-five  Mouth 
Hygiene  units  operated  eleven  half  days  per  week,  which  would  care  quite 
well  for  seventy  or  seventy-five  thousand  children. 

The  amount  of  surgical  service  under  anaesthesia  required  would  be  in- 
creased by  the  fifteen  Mouth  Hygiene  units  above  referred  to,  to  the  extent 
that  probably  five  half-day  clinics  will  be  required  every  week  at  the  City 
Hospital.  Should  the  Board  of  Education  undertake  to  solve  their  problem 
as  above  suggested  fully  double  the  amount  of  surgical  service  will  be  required 
in  addition.  Attention  should  be  called  to  the  fact  that  after  a  very  few 
years  the  surgical  service  will  undoubtedly  decrease,  for  if  the  Mouth  Hygiene 
movement  is  of  real  value  there  should  be  little  demand  for  the  surgical 
service  for  school  children  after  the  first  seven  years.  It  would  be  desirable 
to  have  three  hospitals  suitably  located  provide  for  the  surgical  dental  service. 

*A  full-time  resident  dental  surgeon  has  been  placed  on  duty  now,  and  the  clinic  is  open  all  day, 
s  even  days  a  week. 


686  Hospital  axd  Health  Survey 

We  suggest  that  this  service  could  well  be  united  with  the  nose  and  throat 
service  as  the  equipment  in  many  respects  is  similar. 

All  the  groups  with  whom  the  Survey  staff  have  come  in  contact,  such  as 
visiting  nurses,  charity  and  social  agencies,  settlement  houses  and  the  foreign- 
born  have  emphasized  the  inadequacy  of  dental  service  in  Cleveland.  When 
it  is  seen, that  almost  as  much  public  dental  dispensary  service  is  provided 
in  Boston  in  a  week  as  in  Cleveland  in  a  year,  the  reason  for  complaint  is 
plain. 

It  would  be  wholly  superjluous  to  offer  arguments  for  the  need  of  mouth 
hygiene  among  the  children  in  the  public  or  parochial  schools.  The 
matter  is  amply  argued  by  records  of  the  incidence  of  dental  defects  in  the 
office  of  the  bureau  of  School  Medical  Inspection  and  by  the  record  of  ac- 
complishment a  few  years  ago  at  the  Marion  School. 

Dispensary  dental  work  in  every  case  has  fallen  short  of  its  possibilities 
where  there  has  been  either  no  supervision,  or  supervision  by  unpaid  or 
underpaid  men.  The  service  in  Rochester  would  never  have  been  a  success 
without  Dr.  Burkhart,  or  his  like,  as  a  leader;  nor  would  the  service  in  Bos- 
ton have  been  a  success  without  Dr.  Cross,  or  one  of  his  kind,  at  the  head. 
In  the  same  way  the  work  in  Cleveland  will  not  be  a  success  if  we  expect  to 
secure  as  a  leader  in  this  work  a  man  at  $3,303.00  a  year,  nor  can  the  work 
be  carried  on  much  longer  without  paid  supervision. 


DENTAL  SERVICE  IX  HOSPITALS 

It  is  accepted  in  many  hospitals  of  many  cities  that  the  professional  staff 
is  incomplete  without  dental  surgery  represented  and  sharing  in  staff  respon- 
sibilities. A  dentist  should  be  appointed  on  the  attending  staff  of  every 
one  of  the  larger  general  hospitals  of  Cleveland,  with  a  definite  service  in 
wards  and  dispensary. 

The  hospitals  and  other  institutions  in  Cleveland  now  providing  some 
dental  surgery  for  patients  are  as  follows: 

Mount  Sinai  Hospital 

There  are  on  the  staff  of  Mount  Sinai  Hospital  two  dental  consultants. 
Dental  and  Oral  Surgery  is  the  only  service  provided.  Such  cases  as  seri- 
ously need  prophylaxis  are  sent  to  the  Dental  College.  The  Dental  and 
Oral  Surgery  dispensary  is  open  from  8:30  to  10:00  A.  m.  on  each  Monday 
and  Thursday.  The  Dental  and  Oral  Surgeons,  being  members  of  the  staff, 
enjoy  the  privilege  of  operating  upon  private  patients  at  the  hospital,  for 
which  they  may  receive  fees  as  in  all  departments  of  the  hospital;  however, 
no  compensation  is  received  by  the,  dentists  from  dispensary  or  open  ward 
patients.  The  present  dispensary  facilities  are  one  dental  chair  with  the 
necessary  equipment,  located  in  the  annex  where,  with  the  present  staff  and 
time  (two  mornings  per  week),  about  eight  hundred  cases  per  annum  may 
be  cared  for.     Cases   are   admitted   for  dental  surgery  only.     The  hospital 


Professional  Education  and  Practice  687 

plans  the  enlarging  of  this  service  in  the  near  future,  together  with  the 
addition  of  prophylactic  service.  There  is  no  opportunity  to  develop  a  purely 
dental  oral  surgery  service  for  out-patients  at  the  present  time. 

Cleveland  City  Hospital 

The  City  Hospital  maintains  a  dental  surgery  department,  the  operating- 
room  being  situated  in  an  amphitheater  in  the  female  division  on  the  ground 
floor  of  the  main  building.  The  outfit  consists  of  one  operating  chair,  vari- 
ous nitrous  oxide  machines  and  a  fair  equipment  of  instruments  for  dental 
oral  surgery,  together  with  instruments  for  other  forms  of  dental  service  that 
are  likely  to  be  necessary  in  the  care  of  the  regular  hospital  patients.  The 
staff  of  the  City  Hospital  consists  of  a  Visiting  Dental  Surgeon,  a  Visiting 
Dental  Anaesthetist,  a  Resident  Dental  Surgeon,  temporarily  spending  half 
time;  and  one  or  two  nurses  assigned  to  the  service  as  needed.  Out-patient 
service  for  dental  oral  surgery  is  rendered  on  each  Friday  from  1  to  4  p.  M. 
An  average  of  fifteen  extraction  cases  are  cared  for  each  afternoon.  During 
the  past  two  years  [some  fifteen  hundred  anaesthesias  have  been  ad- 
ministered. This  service  is  inadequate  in  volume  and  should  be  increased  at 
the  earliest  possible  time.  The  most  reasonable  and  economic  manner  of 
increasing  the  service  in  the  present  building  will  be  by  providing  two  or 
more  separate  operating  rooms  (adjacent  but  entirely  separate)  and  each 
having  its  own  equipment.  A  waiting  room  should  be  provided  for  the 
dental  cases.  The  corridor  is  now  used.  The  entire  service  should  be 
upon  the  level  of  the  main  floor  and  as  near  as  possible  to  an  entrance  to  the 
building.  With  the  suggested  arrangement  the  volume  of  cases  could  be 
largely  increased  with  a  minimum  outlay  of  expense  and  a  minimum  increase 
in  staff  personnel. 

Children's  Fresh  Air  Camp 

A  dentist  spends  two  half  days  per  week  at  the  Fresh  Air  Camp.  He 
cares  for  the  children  of  the  institution  only.  Simple  extractions  are  made 
under  novocain.  More  serious  work  requiring  general  anaesthesia  is  referred 
to  the  City  Hospital. 

Jewish  Orphan  Asylum 

Two  dentists  each  spend  a  full  day  per  week  at  the  Asylum.  General 
service  is  rendered  the  children.  Simple  extractions  are  made  with  the  use 
of  novocain.  More  serious  cases  requiring  a  general  anaesthetic  are  taken 
on  occasions  to  the  dentist's  private  office.  Service  is  for  the  children  of  the 
institution  only. 

St.  Luke's  Hospital 

There  is  no  official  dental  appointment  on  the  staff  of  St.  Luke's  Hospital. 
However,  a  dentist  administers  anaesthetics  almost  constantly  and  is  recog- 
nized by  the  staff,  but  has  no  appointment.  On  rare  occasions  this  dentist 
removes  teeth,  but  no  dental  service  is  provided. 


088  Hospital  and  Health  Survey 

Lakeside  Hospital 

At  present  there  is  no  official  dental  service  at  Lakeside  Hospital;  how- 
ever, we  are  informed  that  such. is  under  consideration  and  will  probably  be 
inaugurated  at  an  early  date. 

•j  Cleveland  State  Hospital  for  the  Insane 

The  State  Hospital  has  not  at  the  present  time  a  dentist  on  its  staff  and 
has  not  had  for  a  year  or  two  past.  We  are  informed  that  they  have  no 
appropriation  for  that  purpose,  therefore  do  not  anticipate  such  an  appoint- 
ment in  the  near  future.  The  State  Hospital  for  several  years  furnished 
dental  service  to  the  inmates. 

St.  Vincent's  Charity  Hospital 

At  the  present  time  there  is  no  dental  service  at  St.  Vincent's  Charity 
Hospital.  In  many  respects  Charity  Hospital  would  be  an  ideal  location 
for  a  Dental  and  Oral  Surgery. 

Mention  of  dental  service  in  industry  will  be  found  in  the  Industrial 
Hygiene  Survey,  Part  VII.  A  limited  service  of  high  quality  is  provided 
in  five  establishments  approximately  at  cost.  There  is  urgent  need  for  more 
dentists  in  industry  and  the  need  would  seem  to  justify  inclusion  of  some  of 
the  special  dental  hazards  in  industry  in  the  dental  curriculum. 

COLLEGE  OF  DENTISTRY 

This  professional  school  has  passed  through  many  financial,  educational 
and  administrative  vicissitudes  and  at  present  is  within  reach  of  standards 
and  support  which  will  entitle  it  to  rank  with  the  best. 

Its  present  needs  are  more  teaching  room,  a  moderate  increase  in  its  equip- 
ment, a  small  outlay  for  a  simple  teaching,  reference  and  periodical  library, 
improvement  in  the  teaching  of  anatomy  and  pathology  in  conformity  with 
the  high  conceptions  and  standards  of  these  departments  in  the  medical 
school  and  a  considerable  increase  (10)  in  the  teaching  staff,  especially  of 
full-time  men  in  the  laboratory  and  clinical  courses. 

More  students  are  now  accepted  than  can  properly  be  accommodated 
and  taught.  An  increase  of  50%  in  the  space  is  needed,  if  an  entering  class 
of  75  is  accepted.  It  is  estimated  that  $200,000  will  be  needed  for  additional 
space  in  the  next  five  years.  Probably  $10,000  would  meet  the  lack  of 
equipment  now. 

The  absolutely  indispensable  in  the  way  of  books  and  periodicals  for 
teachers  and  students  would  cost  about  $4,000. 

To  pick  teachers  of  dentistry  simply  from  among  successful  practitioners 
will  continue  here  the  same  misfortunes  and  inadequacies  which  have  been 
a  plague  to  medical  education.  The  men  selected  must  expect  to  make 
teaching  a  career  and  be  fit  to  employ  permanently  as  such. 


Professional  Education  and  Practice  689 

As  soon  as  the  obligations  assumed  by  the  University  when  it  took  over 
the  school  from  its  commercial  supporters  are  paid  off  an  endowment  should 
be  raised  for  the  support  of  dental  teaching.  Within  the  next  five  years 
this  school  needs  a  million  and  a  quarter  of  dollars  to  provide  the  grade  of 
education  for  which  applicants  are  clamoring,  in  numbers  the  University 
cannot  accept. 

The  College  of  Dentistry  would  profit  greatly  from  organized  interest, 
criticism  and  support  by  the  Cleveland  Dental  Society.  The  school 
and  the  profession  cannot  get  along  without  each  other  and  for  the  credit  of 
both  they  should  have  mutual  support,  which  does  not  exist  at  present. 

There  are  no  facilities  for  graduate  education  of  dentists.  They  should 
be  developed  and  offered  by  the  college. 


THE  DENTAL  HYGIEXIST 

In  the  interest  of  public  service,  to  provide  trained  aids  to  the  prac- 
tising dentist,  to  keep  pace  with  the  practice  in  leading  states  of  the  country, 
it  seems  evident  that  the  College  of  Dentistry  should  undertake  the  training 
of  dental  hygienists  and  should  support  the  efforts  of  the  organized  profes- 
sion to  obtain  the  amendments  in  the  State  Civil  Code  necessary  to  legal- 
ize this  profession  in  Ohio. 

Dental  repair  work  among  children  has  been  reduced  by  50%  by  the  em- 
ployment of  dental  hygienists. 

The  modifications  in  the  State  Civil  Code  proposed  by  the  Cleveland 
Mouth  Hvgiene  Association  (affecting  bv  slight  changes  in  the  wording- 
sections  1320A,  1321A,  1320B,  1321B,  1321C,  1321D,  1321E,  1323A,  1324A, 
1324B,  1324C)  are  strongly  approved,  and  it  is  our  opinion  that  the  changes 
might  well  go  further  and  permit  the  practice  of  dental  hygienists  in  private 
offices  of  dentists  as  well  as  in  institutions.  Such  modifications  have  been 
made  and  have  met  with  uniform  satisfaction  in  eleven  other  states,  includ- 
ing Connecticut,  Massachusetts,  New  York  and  Maine. 

There  are  two  important  professionally  supported  activities  in  the  field 
of  dentistry  of  considerable  importance  in  Cleveland.  One,  the  Dental 
Research  Laboratory  of  the  National  Dental  Society,  has  been  a  center  of 
important  studies  in  the  interest  of  exact  scientific  practice.  The  other, 
a  distinctly  local  organization,  the  Cleveland  Mouth  Hygiene  Association, 
must  be  credited  with  most  if  not  all  that  has  been  done  in  the  field  of  public 
education  in  preventive  dentistry  and  oral  hygiene  in  the  city.  From  modest 
beginnings  in  1897,  when  its  influence  was  first  felt  in  the  better  teaching  of 
school  children,  this  Association  developed  increasing  puplic  support  and 
resources.  In  1905  it  maintained  the  dental  dispensary  at  City  Hospital. 
In  1914  money  was  raised  sufficient  to  pay  expenses  of  operating  six  school 
dental  dispensaries.     Since  then  the  Board  of  Education  has  paid  for  them. 

The  work  of  the  Association  has  continued  to  be  effective  and  their 
budget  of  $11,533  for  1920  to  defray  the  expenses  of  the  five  dispensaries 
at  Health  Centers  was  approved  by  the  Welfare  Federation. 


690  Hospital  and  Health  Survey 

The  Survey  is  indebted  to  officers  of  each  of  the  professional  groups 
above  considered  for  information  and  advice. 

RECOMMENDA  T/ONS 

It  is  recommended  that: 

1 .  Measures  be  taken  to  obtain  such  amendments  to  the  State  Civil  Code  as  will  permit 
the  licensing  of  dental  hygienists  and  their  employment  in  private  practice  and  in 
public  institutions,  under  the  direction  of  licensed  dentists. 

2.  The  State  Civil  Code  be  amended  to  require  the  annual  registration  of  licensed  dentists. 

3.  The  training  of  dental  hygienists  be  undertaken  by  the  College  of  Dentistry. 

4.  Sufficient  financial  support  be  obtained  for  the  College  of  Dentistry  to  provide  ade- 
quate increase  of  space,  teachers  and  equipment,  a  library,  and  freedom  from  debt  on 
account  of  obligations  to  commercial  interests. 

5.  The  Board  of  Education  aim  to  provide  a  gradually  increasing  service  which  within 
the  next  five  years  will  put  all  school  children  under  adequate  periodical  dental 
inspection,  cleansing  and  repair.  Prophylactic  cleansing  of  children's  teeth  twice  a 
year  is  adequate.     Tooth  brush  drill  should  be  a  part  of  school  education. 

6.  Those  responsible  for  the  children  attending  the  parochial  schools  institute  dental' 
service  similar  or  equivalent  to  that  advised  for  the  children  of  the  public  schools. 

7.  Administration  of  all  public  dental  school  and  dispensary  services  supported  by  the 
tax  payers  be  put  under  the  direction  of  one  competent  full-time  paid  dentist,  within 
the  Division  of  Health  or  under  the  Board  of  Education. 

8.  The  dental  surgical  service  at  City  Hospital  be  increased  fourfold. 

9.  The  dental  surgical  service  for  out-patients  at  Mt.  Sinai  be  increased  as  soon  as  funds 
can  be  obtained. 

10.  The  Hospital  Council  prevail  upon  at  least  two  other  of  the  privately  endowed  hos- 
pitals to  establish  out-patient  dental  service. 

11.  A  dental  surgeon  be  appointed  on  the  visiting  staff  of  each  of  the  larger  general  hos- 
pitals and  a  dental  interne  be  provided  to  carry  out  such  prophylactic  and  reparative 
work  on'  patients  as  their  condition  permits  or  requires. 

12.  A  dentist  be  provided  at  Warrensville  Infirmary. 

13.  Both  medical  students  and  nurses  receive  in  their  preparation  to  practice,  instruction 
in  the  principles  of  the  cause  and  prevention  of  dental  disease  and  that  nurses  receive 
practical  training  in  the  technic  of  cleansing  patients'  teeth. 


Professional  Education  and  Practice  691 

Pharmacy  in  Cleveland 

By  Haven  Emerson,  M.  D. 

AS  the  knife  is  to  the  surgeon,  so  the  drug  or  chemical  is  to  the  physician, 
and  there  must  be  keenness  and  strength  and  appropriateness  in  each. 
Whether  we  look  upon  the  pharmacist  as  the  dispenser  of  package 
goods  over  the  counter,  the  compounder  of  special  remedies  or  physicians' 
prescriptions,  as  an  analytical  chemist  or  as  a  wholesale  manufacturer  of 
standard  drugs  and  biological  products,  he  is  as  indispensable  an  auxiliary 
to  the  physician  in  the  medical  service  of  the  community  as  are  the  dentist 
and  the  nurse.  His  education,  the  conditions  of  his  employment,  his  protec- 
tion against  illegal  practitioners,  his  standards  and  his  aspirations  are  all 
matters  of  importance  to  the  public  health  and  to  the  welfare  of  the  sick. 

In  the  absence  of  any  authoritative  or  official  registry  of  licensed  or  gradu- 
ate pharmacists  in  Cleveland,  and  using  the  figures  available  from  the  roster 
of  the  Northern  Ohio  Druggists'  Association  and  the  lists  in  the  hands  of 
local  wholesale  drug  supply  houses,  we  can  estimate  that  there  are  at  the 
present  time  about  400  drug  stores  and  probably  500  or  more  registered 
pharmacists  and  registered  assistant  pharmacists  in  Greater  Cleveland. 

Probably  ten  per  cent  of  the  above  number  have  had  no  college  training 
and  it  is  safe  to  say  that  seventy-five  per  cent  have  had  it.  What  number 
have  had  some  college  training  but  did  not  graduate  in  pharmacy  it  is  im- 
possible to  estimate. 

The  length  of  courses  taken  by  those  who  graduated  was  either  two  or 
three  years. 

The  major  portion  of  the  pharmacists  here  who  have  had  college  training- 
received  it  at  the  Cleveland  School  of  Pharmacy  prior  to  the  time  when  it 
became  an  integral  part  of  Western  Reserve  University.  Some  few  gradu- 
ated from  Ohio  State  University,  Ohio  Northern  University,  the  University 
of  Michigan,  The  Cincinnati  College  of  Pharmacy  and  the  Philadelphia 
College  of  Pharmacy. 

PHARMACY  LAWS 

Prior  to  August,  191.5,  anyone  could  take  the  state  examination  offered 
by  the  State  Board  of  Pharmacy  for  registered  pharmacist  or  registered 
assistant  pharmacist  if  he  had  served  an  apprenticeship  of  four  years  in  a 
retail  drug  store. 

If  the  applicant  had  attended  a  school  of  pharmacy  he  usually  received 
credit  on  his  "experience  requirement"  for  the  time  he  spent  in  school. 

Schools  of  pharmacy  made  no  requirement  of  high  school  education  for 
entrance  until  a  few  years  ago  when  they  began  to  require  one  year  of  high 

*We  are  indebted  to  Mr.  Edward  Spease,  Dean  of  the  School  of  Pharmacy  of  Western  Reserve 
University  for  valuable  aid  in  preparing  this  chapter  and  for  information  dealing  with  drug  supplies  for 
hospitals  and  in  the  question  of  proprietary  medicinal  preparations. 


692  Hospital  and  Health  Survey 

school  training.    Some  few  university  schools  have  of  course  for  some  years 
past  demanded  high  school  graduation  as  a  requisite  for  entrance. 

In  1915  the  Ohio  Legislature  passed  a  law  requiring  two  years  of  high 
school  study  for  entrance  into  recognized  pharmacy  schools  and  that  the 
applicant  be  a  graduate  of  one  of  these  recognized  schools.  The  matriculant 
must  also  obtain  an  entrance  certificate  from  the  State  Board  of  Pharmacy 
and  this  certificate  is  issued  by  an  entrance  examiner  who  may  evaluate 
credits  or  give  examinations  to  obtain  them.  This  entrance  ex- 
aminer himself  must  be  a  college  graduate  with  the  degree  of  A.  B.  or  B.  S. 
and  must  not  be  connected  directly  or  indirectly  with  any  pharmacy 
school.  This  examiner  besides  his  experience  as  a  high  school  teacher  is  to- 
day an  employe  of  the  State  Department  of  Public  Instruction. 

The  legislature  in  1919  passed  an  amendment  to  the  Pharmacy  Law 
requiring  four  years  of  high  school  for  entrance  into  a  pharmacy  school. 
This  must  be  upon  diploma  after  four  years  of  study  in  a  high  school,  normal 
school  or  academy,  or  be  by  examination  given  by  the  state  board  entrance 
examiner. 

The  course  of  study  given  to  a  student  in  a  recognized  school  must  con- 
form to  the  Pharmaceutical  Syllabus  of  1913,  which  was  prepared  by  the 
American  Pharmaceutical  Association,  the  American  Conference  of  Phar- 
maceutical Faculties  and  the  National  Association  of  Boards  of  Pharmacy. 
The  least  course  given  must  be  of  two  years'  duration,  consisting  of  certain 
didactic  and  laboratory  hours  totaling  not  less  than  1,200  in  all.  The  course 
must  be  given  entirely  in  the  day  time  and  two  months  must  elapse  between 
the  two  school  years.  Not  less  than  three  full-time  professors  must  be 
employed. 

Some  of  the  Ohio  schools  and  notably  the  Western  Reserve  University 
school  exceed  this  minimum.  Here  the  school  years  and  hours  per  week 
are  of  university  length  and  the  work  is  of  university  grade.  A  total  of 
more  than  1,700  hours  is  given  for  this  two  years'  course.  Four  full-time 
instructors  and  nine  part-time  instructors  are  employed. 

Among  the  laws  governing  the  practice  of  pharmacy  are  to  be  found  all 
the  Pure  Food  and  Drug  laws,  Narcotic  laws,  Prohibition  laws,  Poison  laws 
and  special  regulations  governing  the  sale  of  drugs  in  drug  stores. 


ADEQUACY  AND  ENFORCEMENT  OF  LAWS 

The  laws  now  governing  pharmacy  would  be  entirely  adequate  if  there 
were  not  so  many  exceptions  to  them.  As  they  now  stand  they  are  quite 
rigorous  enough  concerning  what  is  to  be  sold  and  how  it  is  to  be  sold  in  drug 
stores,  but  the  exceptions  to  the  laws  permit  anyone  to  compound  patent 
medicines  and  sell  simples,  such  as  Epsom  salts  and  the  like,  in  stores  other 
than  drug  stores  or  from  wagons  or  by  house-to-house  canvass.  Many 
poisonous  substances  may  also  be  sold  if  put  up  in  packages  bearing  proper 
labels. 


Professional  Education  and  Practice  693 

One  of  the  tendencies  of  the  present  time  is  for  druggists  to  cease  manu- 
facturing preparations  for  their  store  use  and  to  buy  these  preparations 
ready  made.  This  has  been  brought  about  partly  by  the  fact  that  manu- 
facturers have  secured  laws  through  which  they  may  purchase  tax  free  alco- 
hol for  the  manufacture  of  such  preparations  as  tincture  of  iodine  and  cer- 
tain other  preparations  where  there  is  absolutely  no  question  of  the  alcohol 
being  completely  denatured.  The  objection  to  this  lies  solely  in  the  fact 
that  the  Government  denies  this  privilege  of  economical  purchase  of  alcohol 
to  the  retailer,  by  requiring  this  alcohol  to  be  secured  in  large  quantities  and 
to  be  denatured  with  the  iodine  or  other  substance  at  the  distillery.  This 
enables  the  manufacturer  to  make  and  sell  many  standard  drugs  much 
cheaper  than  can  the  retailers.  The  same  privilege  should  be  extended  to 
the  retailer  or  to  groups  of  retailers.  Anything  that  limits  the  retail  drug- 
gist's professional  practices  tends  to  discourage  and  suppress  his  ability.  In 
like  manner  the  prescribing  of  proprietary  preparations  by  the  physician 
lessens  the  druggist's  practice  and  hence  his  ability  to  compound.  Few 
physicians  think  out  and  write  their  prescriptions  with  a  definite-purpose  for 
the  use  of  each  ingredient. 

The  habit  of  "counter  prescribing"  is  not  as  prevalent  as  is  supposed 
but  is  always  augmented  in  a  neighborhood  where  a  dispensing  physician 
resides.  Two  things  will  overcome  this  practice  entirely,  one  is  strict  enforce- 
ment of  law  relative  to  this  practice  and  the  other  is  education  both  of  the 
physician  and  of  the  pharmacist.  It  is  rare  to  see  a  druggist  who  is  a  thor- 
oughly educated  and  cultured  man  do  very  much  counter  prescribing  or  do 
more  along  this  line  than  to  sell  medicines  of  the  customer's  own  selection. 
It  is  not  rare  to  find  this  druggist  often  advising  the  customer  to  go  to  a 
physician. 

A  much  better  type  of  drug  store  service  would  be  available  if  the  law 
requiring  a  registered  pharmacist  to  be  actually  in  a  retail  drug  store,  hos- 
pital or  industrial  plant  pharmacy,  and  other  places  where  drugs  are  com- 
pounded and  dispensed,  were  rigidly  enforced. 

That  these  exceptions  are  tolerated  is  due  to  the  lack  of  knowledge  on  the 
part  of  the  public  as  to  the  danger  of  indiscriminate  sale  of  drugs  and  poisons 
and  to  the  apathy  of  physicians  in  supporting  measures  to  remedy  these 
conditions. 

About  the  only  thing  that  may  not  be  done  outside  of  a  drug  store  is 
prescription  filling. 

The  State  Board  of  Pharmacy  is  permitted  to  hire  only  one  inspector  to 
see  that  drug  stores  have  a  registered  pharmacist  in  them  at  all  times  and  to 
see  that  proper  registration  of  bulk  poisons  is  made.  This  inspector  may  not 
receive  much  over  $1,400  per  annum  and  of  course  he  must  be  responsible 
for  the  entire  state.  This  means  that  not  even  the  drug  stores  are  forced  to 
obey  the  laws,  to  say  nothing  of  the  dispensing  of  drugs  indiscriminately  by 
unqualified  persons  in  hospitals,  industrial  plants  and  stores  other  than 
drug  stores. 


694  Hospital  and  Health  Survey 

The  clause  of  the  Ohio  Statutes  requiring  a  registered  pharmacist  to  be 
in  actual  and  personal  charge  of  a  drug  store  at  all  times  is  not  rigidly  en- 
forced, due  largely  to  lack  of  inspectors  to  secure  evidence,  and  indeed  it 
seems  scarcely  necessary  to  attempt  its  enforcement  when  drugs  may  be 
indiscriminately  compounded  and  sold  by  anyone  if  only  the  vendor  does 
not  call  his  place  of  business  a  drug  store. 

The  city  of  Cleveland  has  no  rules,  laws  or  regulations  governing  drug, 
stores,  with  the  exception  of  the  narcotic  ordinance  and  the  general  sanitary 
ordinances. 

COOPERATION  WITH  THE  HEALTH  DEPARTMENT 

The  druggists  of  Cleveland,  through  their  organization,  The  Northern 
Ohio  Druggists'  Association,  an  incorporated  body,  have  been  able  to  aid 
the  Health  Department  greatly  in  correcting  many  abuses  in  sales  of  drugs 
and  medicines.  They  have  appointed  an  advisory  board  who  meet  with  the 
City  Chemist,  at  his  request,  upon  matters  in  which  they  are  interested. 
When  mistakes  have  been  made  in  prescription  filling,  in  drug  stores,  these 
mistakes  have  been  brought  to  the  attention  of  all  the  stores  and  aid  has  been 
given  the  department  in  the  rectifying  of  these  mistakes. 

The  most  important  feature  of  the  work  is  in  the  review  of  patent  medi- 
cines. The  druggists  have  agreed  not  to  stock  patent  medicines  unless  they 
have  been  submitted  to  the  City  Chemist  for  approval  of  label  and  claims, 
and  whenever  the  City  Chemist  issues  an  order  for  the  removal  of  a  patent 
or  proprietary  medicine  from  the  Cleveland  market  the  druggists  have  refused 
to  sell  this  preparation  until  the  order  has  been  rescinded.  The  force  of  this 
is  that  the  City  Chemist  need  not  bring  suit  against  the  druggist  or  druggists 
in  question  to  restrain  a  sale,  but  that  the  burden  of  proof  is  upon  the  manufac- 
turer and  he  must  either  convince  the  City  Chemist  of  the  merit  of  his  claims 
or  must  bring  suit  against  him.  No  suits  have  been  brought  by  such  manu- 
facturers, nor  is  it  at  all  likely  that  such  suits  will  be  brought,  as  long  as  there 
is  judgment  and  honesty  used  in  issuance  of  the  orders  by  the  City  Chemist; 
for  the  bringing  of  a  suit  would  require  the  disclosure  of  the  ingredients  of 
the  proprietary  medicine  and  at  once  the  value  of  the  nostrum  would  be 
dissipated  since  secrecy  and  the  claims  of  a  therapeutic  value  based  on  worth- 
less or  inert  ingredients  is  the  basis  of  this  whole  colossal  fraud.  The  inge- 
nuity and  effectiveness  of  this  method  of  repression  of  valueless  or  fraudu- 
lent patent  medicines  is  worthy  of  imitation  in  other  cities  and  states.  This 
and  the  appreciation  by  the  press  of  the  value  of  honest  drug  advertisements 
would  soon  stop  a  national  disgrace,  save  the  public  millions  of  loss  annu- 
ally and  spare  the  ignorant  and  the  ailing  the  disappointment  of  useless 
medication. 

THE  SCHOOL  OF  PHARMACY 

The  School  of  Pharmacy  of  Western  Reserve  University  was  founded  in 
1883  by  the  local  druggists.  At  that  time  only  a  series  of  lectures  were  given 
to  apprentices.     From  this  small  beginning  it  grew  until  two  courses  were 


Professional  Education  and  Practice  695 

given,  one  of  two  years'  duration  and  one  of  three  years'  duration.  Until 
the  fall  of  1917  these  courses  were  arranged  so  that  the  student  could  go  to 
school  three  days  a  week  and  work  on  alternate  days  in  a  retail  drug  store. 
Since  the  fall  of  1917  the  student  has  been  required  to  put  in  full  university 
hours  in  school,  both  per  week  and  per  year.  The  two-year  course  is  now 
perfected  upon  the  basis  of  giving  the  student  two  years  of  college  work  of 
university  length  and  quality.  The  school  is  located  in  a  building  in  the 
heart  of  the  business  district,  which  today,  due  to  traffic  and  business  condi- 
tions, does  not  permit  the  use  of  delicate  instruments  for  instructional  pur- 
poses. The  surroundings  detract  greatly  from  the  educational  value  of  the 
school. 

The  faculty  consists  of  four  full-time  instructors,  three  of  whom  have  the 
university  degree  of  B.  S.  and  two  of  whom  have  an  additional  degree  of 
M.  S.  One  of  those  with  a  degree  of  B.  S.  has  no  pharmaceutical  degree,  but 
two  of  them  have  the  degree  of  Pharmaceutical  Chemist.  The  fourth  in- 
structor mentioned  above  has  the  degree  of  Graduate  in  Pharmacy  and 
the  degree  of  Pharmaceutical  Chemist. 

Part-time  instruction  is  given  by  nine  other  men,  one  with  the  degrees 
of  A.B.,  A.  M.  and  M.  D.,  another  with  the  degrees  of  A.  M.  and  LL.  B., 
another  with  the  degrees  of  A.  B.  and  A.  M.,  another  with  the  degree  of 
A.  B.  The  others  are  laboratory  assistants,  one  of  them  a  senior  in  the 
college  of  liberal  arts  during  the  past  year. 

As  the  School  of  Pharmacy  grows  the  laboratory  assistants  will,  as  op- 
portunity offers,  be  chosen  from  among  the  graduate  students. 

The  School  of  Pharmacy  has  been  financed  during  all  these  years  from 
tuition  fees  and  by  gifts  from  the  local  druggists.  This  method  of  financing 
does  not  permit  of  very  much  development  toward  better  things  and  indeed 
at  present  almost  forbids  growth. 

The  School  of  Pharmacy  needs: 

(a)  Location  on  the  University  campus,  a  move  which  is  planned  for  the 
immediate  future. 

(b)  Endowment  of  approximately  one  million  dollars,  or  pledges  for  annual 
support  amounting  to  the  interest  on  that  amount  at  five  per  cent. 

(c)  Greenhouses  and  a  medicinal  plant  garden,  to  serve  the  double  purpose 
of  providing  live  material  for  demonstration  and  research  (instead  of 
relying  at  present  upon  the  dried  "cadaver"  material  of  the  commercial 
market)  and  of  furnishing  fresh  drugs  of  standard  tested  quality  to  the 
hospitals  of  the  city.  The  value  of  fresh  herbs,  as  in  the  measurement 
and  study  of  the  effects  of  belladonna  and  digitalis,  for  instance,  is  obvi- 
ous. The  effect  of  soil,  temperature  and  other  cultural  conditions  on  the 
quality  of  drugs  could  be  studied  with  great  advantage. 

(d)  Expansion  of  the  courses  to  permit  of  granting  a  degree  of  B.  S.  after 
four  years  of  study,  to  properly  qualified  students,  men  and  women.  This 
expansion  should  permit  of  a  four-year  study  of  chemistry  and  should 


696  Hospital  and  Health  Survey 


include  physics,  mathematics  and  certain  academic  or  cultural  studies 
and  languages  to  permit  the  pharmacist  to  be  an  educated  as  well  as  a 
trained  graduate.  This  plan  is  now  in  existence  in  all  the  large  universi- 
ties of  the  Middle  West  and  West.  The  pharmacy  schools  east  of  Ohio 
are  nearly  all  on  the  every-other-day  plan,  as  mentioned  above.  New 
York  and  Pennsylvania  schools  will  not  go  upon  the  basis  of  requiring 
high  school  graduation  for  entrance  for  another  couple  of  years. 

(e)  Additional  instructors.  The  school  is  now  doing  no  research  and  it  can 
neither  maintain  its  present  standing  nor  progress  unless  its  teachers  be 
productive.  The  research  problems  confronting  the  student  of  phar- 
mecy  are  many  and  it  is  indeed  discouraging  to  scholars  to  be  so  bur- 
dened with  teaching  that  they  can  give  no  thought  to  research.  Valu- 
able cooperative  research  facilities  should  be  made  available  through 
joint  studies  with  the  Department  of  Pharmacology  of  the  Medical 
School,  which  has  already  made  so  many  notable  contributions  to  scientific 
therapeutics. 

(f)  A  Manufacturing  and  Professional  Service  for  Hospitals.  The  School 
should  equip  a  manufacturing  laboratory  where  preparations,  liquid, 
solid  and  tablet  form,  should  be  produced  for  the  hospitals.  This  would 
not  only  create  an  incentive  for  good  work  on  the  part  of  the  students 
but  would  show  them  during  their  formative  period  that  habits  of  exact- 
ness are  necessary  and  that  their  work  is  directly  related  to  public  health. 

The  elimination  of  high  overhead  charges  and  the  manufacture  on  a  cost 
basis  in  such  quantities  as  the  hospitals -now  use  cannot  help  but  materially 
lessen  cost  of  all  such  materials  to  the  hospitals.  It  is  inferred  in  the  above 
writing  that  each  hospital  maintains  a  pharmacy  and  complies  with  the 
Ohio  Statutes  in  employing  a  registered  pharmacist.  The  Survey  recognizes 
that  this  is  not  a  true  statement  of  existing  conditions.  It  may  be,  however, 
that  small  hospitals  could  have  their  ward  requisitions  or  prescriptions  filled 
at  certain  hours  by  a  traveling  pharmacist  and  his  corps  of  student  assistants, 
or  could  send  them  to  a  larger  hospital  at  certain  intervals  and  have  them 
taken  care  of  properly  in  that  way. 

The  School  of  Pharmacy  of  Western  Reserve  University  can  offer  a  serv- 
ice to  the  hospitals  of  Cleveland  that  may  be  said  to  have  two  direct  objects. 

The  first  is  to  enable  the  hospitals  to  render  a  much  higher  type  of  medical 
service  to  the  public,  and  the  second  is  to  lower  the  cost  of  medicines  to  the 
hospitals.  Under  the  first  heading,  which  is  one  entirely  in  keeping  with 
the  ideals  of  good  hospital  service,  the  Pharmacy  School  should  be  asked  to 
serve  in  an  advisory  capacity. 

1.  It  should  supervise  the  organization  and  arrangement  of  the  hospital 
pharmacies. 

2.  It  should  aid  in  the  purchasing  of  pharmacy  supplies,  inasmuch  as  it  is 
impossible  to  buy  drugs  and  chemicals  intelligently  without  a  direct 
knowledge  of  the  items  themselves  and  of  the  firms  from  which  they  are 
bought.     The  tendency  of  modern  times  is  to  view  drugs  and  medicines 


Professional  Education  and  Practice  697 

as  commodities  only.  This  has  been  brought  about  by  the  rapid  growth 
of  "patent"  and  package  medicines  and  for  this  reason  price  is  sometimes 
the  only  deciding  factor. 

3.  It  can  advise  in  regard  to  the  proprietary  medicines  now  in  use  in  the  hos- 
pitals to  avoid  the  duplication  of  preparations  and  to  show  when  many  of 
these  preparations,  if  needed,  can  be  manufactured  by  the  hospital  phar- 
macy or  by  the  school  organization  as  discussed  later. 

4.  It  can  analyze  and  otherwise  test  the  drugs,  preparations  and  chemicals 
that  are  purchased  after  competitive  bidding,  in  order  that  sick  room  sup- 
plies may  meet  standard  specifications.  This  will  insure  to  the  physicians 
a  knowledge  that  the  substance  supplied  is  exactly  what  it  should  be. 

If  the  above  suggestions  be  carried  out  it  will  result  in  systematizing  the 
pharmaceutical  work  of  the  hospitals  which,  unfortunately,  is  often  lightly 
passed  over  in  perfecting  the  other  seemingly  much  more  important  services 
of  the  hospital.  It  will  also  result  in  directing  all  purchasing  through  one 
office,  such  as  is  maintained  by  the  Hospital  Council,  and  thus  the  supply  of 
any  one  item  for  a  given  period  for  all  hospitals  will  be  purchased  at 
one  time,  entirely  upon  specification  and  with  the  result  of  a  better  price 
for  the  quantity  purchased.  Under  this  last,  or  the  second  heading,  the 
School  of  Pharmacy  should  likewise  carry  out  two  things : 

Furnish  its  senior  students  to  the  hospitals  for  internships. 

This  would  accomplish  two  purposes.  It  would  provide  cheap  but 
efficient  help  to  the  hospital  pharmacist,  enabling  him  to  render  a  service  in 
the  hospital  that  he  is  unable  to  give  under  the  present  arrangement.  This 
is  especially  true  where  free  or  part-pay  clinics  are  conducted  and  medicines 
dispensed.  Besides  demonstrating  the  value  of  an  educated  and  not  "rule- 
of -thumb"  pharmacist  to  the  hospitals  themselves,  it  will  send  out  to 
the  public  men  better  equipped  to  serve  it  by  reason  of  this  high 
type  of  practical  training.  It  need  scarcely  be  added  that  it  will  further 
the  pharmacist's  own  knowledge  of  his  responsibility  to  the  public  whom  he 
serves. 

A  school  of  pharmacy  to  be  efficient  should  have  the  same  academic 
standard  as  a  school  of  medicine.  Unless  the  school  of  pharmacy  is  sup- 
ported as  are  hospitals  and  medical  schools  the  same  menace  will  result  as 
occurred  in  the  era  of  proprietary  medical  schools  and  commercial  hospitals, 
and  the  public  health  will  suffer  instead  of  gain  at  the  hands  of  its  graduates. 

RECOMMEND  A  TIONS 

It  is  recommended  that: 

1.  The  interest  of  the  Academy  of  Medicine  and  of  the  Hospital  Council  be  united 
with  that  of  the  Northern  Ohio  Druggists'  Association  and  of  the  Division  of  Health,  to 
bring  action  through  the  State  Legislature  for  adequate  personnel  and  appropriation  for 
the  enforcement  of  existing  laws  dealing  with  the  presence  of  the  registered  pharmacists 
in  drug  stores  and  hospitals. 


698  Hospital  and  Health  Survey 

2.  Amendments  in  the  laws  of  the  state  be  obtained  which  will  bring  to  an  end 
the  pernicious  practice  of  house-to-house,  street  vendor  and  other  irresponsible  kinds  of 
drug  selling  and  will  restrict  the  sale  of  drugs  to  such  stores  as  have  a  registered  phar- 
macist on  the  premises  during  business  hours. 

3.  Amendment  in  the  state  law  be  obtained  which  will  permit  retail  druggists,  through 
controlled  cooperative  action,  to  obtain  the  benefit  of  the  same  economies  in  the  pur- 
chase of  tax  free  alcohol  as  are  now  the  exclusive  privilege  of  the  large  manufacturers. 

4.  The  policy  of  the  Division  of  Health  in  suppressing  the  sale  of  fraudulent  proprietary 
medicines  be  vigorously  supported  by  the  Chamber  of  Commerce,  the  press  and  by 
the  advertising  interests  of  the  city. 

5.  The  trustees  of  the  University  move  as  rapidly  as  practicable  to  meet  the  needs  as 
indicated  above,  particularly  in  the  matters  of  providing  (a)  greenhouses  and  a  plant 
garden,  (b)  teaching  staff  adequate  to  permit  of  research  as  part  of  the  duties  and 
privileges  of  the  instructors,  (c)  space  and  equipment  to  permit  the  school  to  offer  the 
services  of  its  instructors  and  students  in  the  process  of  education,  to  the  hospitals  of 
Cleveland  and  for  the  testing,  standardizing  and  manufacture  of  drugs  and  chemicals. 

6.  The  Cleveland  Hospital  Council  invite  the  School  of  Pharmacy  to  survey  the  condi- 
tions and  costs  of  hospital  purchase  and  compounding  of  drugs  and  chemicals,  with  the 
object  ultimately  of  obtaining  from  the  staff  and  students  of  the  school  in  return  fbr 
certain  privileges  offered  by  the  hospitals  for  the  training  of  students  in  practical  phar- 
macy, the  consultation  service  and  economies  in  purchase  and  manufacture  which  may 
be  expected  from  such  a  professional  and  educational  group. 

7.  Each  hospital  not  now  purchasing  drugs  and  chemicals  through  the  Central  Purchasing 
Bureau  furnish  the  Bureau  with  a  list  of  drugs  and  chemicals  purchased  by  them  for 
the  past  five  years,  or  failing  such  record,  for  the  ensuing  year,  in  order  that  the  bulk  of 
the  trade  may  be  estimated  and  action  taken  by  the  Hospital  Council  and  the  School 
of  Pharmacy  in  the  interest  of  economy. 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 


j 


List  of  Parts  and  Titles 


I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

.    X      Hospitals  and  Dispensaries. 

XL     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 


The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 


THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Premier  Press 

Cleveland,  O. 


Nursmgf 


Part  Nine 


Cle  velajnd]  Ho  spi  tal     and 
Health    S  ur  ve  y 


.'"  Copyright,  1920", 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
,     308  Anisfield  Bldg. 
Cleveland     -    Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be~|directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were : 

Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators : 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director 'of  the  Hospitarand 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  [Nursing  Survey; 

Wade  Wright,  M.  D.,  Director  of  the' Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the\MentallHygiene% Survey ; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the^Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

Page 

Introductory  Note 707 

I.     Nurses'  Training  in  Cleveland. 

Hospital  Training  Schools 

Standards  of  Comparison _ 709 

A  University  Training  School 710 

Results  of  Field  Study _ 712 

Organization  of  the  Training  School _ 713 

Entrance  Requirements 715 

Capacity  of  Hospitals  and  Service  Offered... _ 716 

Instruction 

Teaching  of  Nursing  Procedures _ 724 

Teaching  of  Fundamental  Sciences. _  728 

Instruction  in  Other  Subjects _ 732 

Conditions  of  Work ' 

Ratio  of  Nurses  to  Patients _ _ 735 

Hours  of  Duty... _ __  736 

Vacation _ 738 

Provision  of  Ward  Helpers __ 738 

Living  Conditions 740 

Recommendations _ _ _ 741 

Postgraduate  Courses 

University  Course  in  Public  Health  Nursing 

Origin 745 

Organization _ 745 

Finances 746 

Staff....... 746 

Students... 747 

Instruction.... 748 

Field  Work 748 

Recommendations 751 

Institute  of  School  Hygiene 752 

II.     Public  Health  Nursing 

Introductory 

Scope  of  Survey 753 

Some  Elements  of  Success 754 

Value  of  the  Generalized  System 754 

Some  Causes  of  Failure 755 


TABLE  OF  CONTENTS— Continued 

Page 

Central  Nursing  Committee 

Organization  756 

Activities A • : 757 

Recommendations 757 

Division  of  Health 

Scppe  of  Work ,. 758 

Present  Staff „...' 759 

Analysis  of  Activities 759 

Analysis  of  Administration. 764 

Recommendations 769 

Visiting  Nurse  Association 

Scope  of  Work 773 

Present  Equipment 774 

Analysis  of  Activities •_ 774 

Analysis  of  Administration..., : 778 

Recommendations 781 

Board  of  Education 

Scope  of  Work 782 

Staff. 783 

Analysis  of  Activities 783 

Analysis  of  Staff  and  Administrative  Methods 786 

Recommendations 788 

University  District 

Analysis  of  Administration 790 

Analysis  of  Activities 790 

Supervision 795 

General  Summary... 795 

Recommendations 796 

Prenatal  and  Maternity  Service 

Present  Service 797 

Types  of  Patients  to  be  provided  for.. 797 

Types  of  Nursing  Care  Needed.... 798 

Appropriate  Agencies  for  a  City-wide  Service.. 798 

Recommendations — 803 

Industrial  Nursing 

Function  of  the  Industrial  Nurse 803 

Types  of  Service  Rendered 804 

Some  Causes  of  Failure... 806 

III.     Some  Notes  on  Private  Duty  Nursing. 

Unnecessary  Employment  of  Full-time  Graduate  Nurses 808 

Employment  of  Trained  Attendants     809 


T 


INTRODUCTORY  NOTE 

HE  Nursing  Survey  and  Report  has  been  in  charge  of  Josephine  Gold- 
mark,  Secretary  of  the  Committee  for  the  Study  of  Nursing  Education, 
and  Anne  H.  Strong,  R.  N.,  Assistant  Secretary  of  the  Committee. 

The  field  work  for  the  study  of  hospital  training  schools  was  done  by 
Mrs.  A.  F.  Piggott,  Maryland  State  inspector  of  training  schools.  A  brief 
study  of  the  teaching  in  the  larger  training  schools  was  made  by  Miss  A.  H. 
Turner,  professor  of  physiology  at  Mt.  Holyoke  College.  In  writing  the 
report  on  the  hospital  training  schools,  assistance  was  rendered  by  Miss 
Pauline  Angell. 

The  investigation  of  public  health  nursing  agencies  in  Cleveland  was  made 
jointly  by  Miss  Elizabeth  G.  Fox,  Director  of  the  Bureau  of  Public  Health 
Nursing  of  the  American  Red  Cross,  and  Miss  Janet  M.  Geister,  Western 
Secretary  of  the  National  Organization  for  Public  Health  Nursing.  To 
Miss  Fox  credit  is  due  for  outlining  the  plan  for  a  Prenatal  and  Maternity 
Nursing  Service  and  for  the  detailed  recommendations  to  the  various  pub- 
lic health  nursing  agencies.  Both  these  investigators,  Miss  Fox  in  particu- 
lar, assisted  in  the  writing  of  these  reports. 

The  field  work  for  the  study  of  industrial  nurses  was  done  by  Mrs. 
Anna  M.  Staebler,  Secretary  of  the  Massachusetts  Committee  on  Health  in 
Industry,  and  some  supplementary  studies  in  this  field  were  contributed  by 
Miss  Wilma  I.  Ball,  Secretary  of  the  Consumers'  League  of  Ohio. 

To  all  the  cooperating  societies,  who  released  their  workers  for  the  Nurs- 
ing Survey  for  varying  periods  of  time,  acknowledgment  and  thanks  are 
due. 


Nurses    Training  in  Cleveland 

Hospital  Training  Schools 

THE  study  of  hospital  training  schools  in  Cleveland  has  covered  the 
thirteen  schools  recognized  under  the  State  Law.  Of  these,  four  were 
studied  in  much  detail  (City  Hospital,  Lakeside.  Mt.  Sinai  and  St.  John's) ; 
the  remaining  nine  were  more  briefly  inspected  (Cleveland  Maternity,  Fair- 
view,  GlenviUe,  Huron  Road,  Lakewood,  St.  Ann's  Maternity,  St.  Alexis, 
St.  Luke's  and  St.  Vincent's.)  The  investigation  centered  upon  all  those 
factors  in  the  hospital  and  the  training  school  which  are  related  to  the  nature 
and  adequacy  of  the  training;  the  adequacy  of  service  to  patients  in  the  hos- 
pital was  considered  only  in  so  far  as  it  bears  upon  the  work  of  the  students. 

The  hospital  training  schools  in  Cleveland  exhibit,  in  greater  or  less 
degree,  the  general  characteristics  which  are  found  in  similar  institutions 
elsewhere.  The  excellence  and  the  weaknesses  inherent  in  the  established 
system  of  instruction,  both  theoretical  and  practical,  are  amply  illustrated 
in  the  various  schools  of  the  city.  They  share  that  spirit  of  devotion  and  ser- 
vice which  has  for  a  half  century  been  the  distinction  and  the  legitimate 
pride  of  the  training  schools  for  nurses;  they  share  also  in  varying  degree 
the  lack  of  standards  and  of  independent  organization,  the  inadequacy  of 
teaching  and  equipment,  and  the  exploitation  of  students,  which  has  been  too 
often  accepted  in  lieu  of  education.* 

STANDARDS  OF  COMPARISON 

The  objects  of  study  and  standards  of  comparison  taken  in  the  study  of 
Cleveland  training  schools  have  in  the  main  been  those  set  forth  as  "reason- 
able and  desirable"  in  1919  by  the  Committee  on  Education  of  the  National 
League  of  Nursing  Education.  Without  subscribing  to  the  details  of  the 
curriculum  there  set  forth,  we  have  measured  the  training  schools  by  these 
recognized  standards  together  with  certain  additions  of  our  own. 

The  standing  of  each  hospital  with  relation  to  the  desirable  standards  is 
discussed  in  this  report;  a  separate  detailed  account  of  each  hospital  has  been 
submitted  to  the  authorities  of  the  institution. 

This  record  brings  out  the  strong  and  the  weak  points  of  nursing  educa- 
tion in  Cleveland,  and  shows  concretely  how  much  remains  to  be  done  to 
bring  the  training  schools  up  to  the  level  which  they  should  reach  to  meet 
the  clinical  opportunities  and  the  clinical  needs  of  the  city. 

To  introduce  radical  innovations  into  any  established  human  institution 
is  obviously  a  slow  and  delicate  task.  In  their  business  of  nursing  the  sick, 
the  hospitals  cannot  at  once,  or  even  within  a  short  period  of  time,  be  deprived 
of  their  present  labor  supply.  Any  changes  must  of  necessity  be  gradual, 
and  in  the  following  report  the  standards  followed  and  the  recommendations 

*  The  investigation  upon  which  the  report  is  based  was  made  in  the  winter  of  1919-1920.  Notable 
improve -nents  have  already  been  made  in  a  number  of  the  hospital  training  schools  since  that  time  and 
many  others  are  under  consideration. 


710  Hospital  and  Health  Survey 

made  for  immediate  adoption  only  approximate  the  conditions  under  which 
students  should  ultimately  be  trained. 

Within  the  required  limits,  undoubtedly  many  desirable  changes  in  indi- 
vidual hospitals  can  be  indicated,  which  will  improve  the  training  now  given. 
But  these  changes  should  be  recognized  as  merely  ameliorative.  They  rep- 
resent temporary  improvements,  not  the  fundamental  reorganization  of  the 
training  school  under  university  auspices,  which  is  needed  for  the  future 
development  of  nursing  education. 

A  UNIVERSITY  TRAINING  SCHOOL 

In  the  possibility  of  a  central  training  school  under  university  auspices, 
Cleveland  has  the  opportunity  of  making  an  important  contribution  to  the 
ultimate  solution  of  the  problem,  the  independence  of  hospital  and  training- 
school,  the  recognition  of  the  nurse-in-training  as  a  university  student 
throughout.  A  preliminary  university  affiliation  has  already  been  tempo- 
rarily and  partially  tried  in  Cleveland.  The  successful  wartime  expedient 
of  providing  college  instruction  in  the  fundamental  sciences  for  88  student 
nurses  during  the  summer  of  1918  set  the  precedent  for  an  extension  of  such 
a  university  connection. 

Moreover,  the  university  has  already  given  proof  of  its  broadminded 
interest  in  permanently  providing  training  of  college  grade  for  young  women 
who  desire  to  enter  this  increasingly  important  branch  of  public  service,  the 
profession  of  nursing.  A  preliminary  plan  has  been  proposed  by  the  uni- 
versity for  a  future  school  or  department  of  nursing,  subject  to  obtaining 
financial  support  for  such  an  undertaking. 

The  plan  proposed,  while  still  tentative,  is  highly  commendable  in  in- 
cluding various  features  essential  for  the  success  of  such  a  central  university 
school.  Briefly  stated,  it  proposes  to  give  a  definite  period  of  college  training, 
chiefly  in  the  introductory  sciences  but  with  some  cultural  studies,  an  equal 
length  of  time  for  hospital  training  and  a  final  academic  period  for  additional 
courses  in  the  nursing  specialties.  For  the  graduates  of  these  courses  both 
the  nursing  diploma  and  the  university  degree  are  to  be  granted. 

In  this  proposal  for  a  School  of  Nursing  a  distinctive  contribution  is  made. 
In  the  few  other  cities  in  which  such  a  five-year  college  and  hospital  course 
is  offered,  the  courses  are  in  combination  with  but  one  or  two  hospitals;  the 
Cleveland  plan  would  be  offered  in  cooperation  with  several  hospitals  to 
start  with  and  with  as  many  additional  ones  as  "can  maintain  standards  of 
training  high  enough  to  warrant  their  recognition. " 

Some  Benefits  of  the  University  Training  School 
Better  Students  and  Better  Instruction 

One  of  the  main  benefits  of  a  university  connection  such  as  the  one  pro- 
posed would  be  to  attract  to  the  profession  of  nursing  young  women  who 
are  now  repelled  by  the  inferior  teaching  provided,  and  the  subordination 
of  their  education  to  the  needs  of  the  hospitals.     In  the  pre-nursing  period 


Nursing  711 

of  instruction,  it  will  be  possible  to  give  science  teaching  of  far  higher  grade 
and  with  laboratory  equipment  far  better  than  provided  in  the  ordinary 
hospital  course. 

Improving  Instruction  on  the  Wards 

A  second  benefit,  upon  which  general  stress  should  be  laid,  is  the  oppor- 
tunity afforded  to  the  university  to  exert  its  influence  in  raising  the  edu- 
cational standards  of  the  hospitals  which  desire  affiliation.  It  is  clear  that 
one  essential  element  of  this  plan  must  be  the  cooperation  of  the  hospital 
in  offering  instruction  in  the  wards  of  such  a  quality  as  to  deserve  the  uni- 
versity degree.  In  our  subsequent  discussion  of  the  Cleveland  hospitals 
the  success  or  failure  of  teaching  in  the  wards  is  indicated.  In  the  possi- 
bility of  refusing  affiliation  to  hospitals  whose  instruction  in  nursing  pro- 
cedures, either  in  the  class  room  or  in  the  wards,  is  below  standard  or  educa- 
tionally wasteful,  the  university  school  can  be  a  potent  force  for  good.  It 
should  use  its  power  of  approval  or  disapproval  freely,  for  in  no  other  way 
than  by  scrutiny  and  criticism  of  the  grade  of  teaching  provided  by  the 
hospital  can  the  educational  side  of  the  training  school  be  sustained  against 
the  exigencies  of  hospital  needs. 

Training  for  Advanced  Work  in  Administration,  Teaching, 
and  Public  Health 

The  special  function  of  the  university  course  will  be  to  prepare  the  leaders 
in  the  different  fields  of  nursing.  Impartial  investigation  finds  crying  need 
for  more  adequately  trained  teachers  and  administrators  in  the  hospitals. 

Such  a  course  would  supply  administrative  heads  with  better  fundamental 
training  and  a  wider  background  than  are  now  general.  The  limited  edu- 
cation of  many  who  are  in  positions  of  responsibility  in  the  training  schools 
has  been  one  cause  of  their  difficulty  in  grappling  with  the  perplexing  prob- 
lems of  the  schools. 

Similarly,  such  a  course  would  help  to  provide  more  adequately  trained 
nursing  instructors.  The  lesser  educational  qualifications  of  instructors  in 
schools  of  nursing  as  compared  with  instructors  in  colleges  and  other  pro- 
fessional schools  is  very  marked.  In  the  schools  of  nursing  the  instructors 
are  frequently  required  to  teach  many  subjects,  often  more  than  teachers  in 
country  high  schools;  yet  for  this  great  task,  they  have  themselves  had  only 
their  own  nurse's  training,  of  perhaps  some  years  past,  sometimes  supple- 
mented by  courses  at  Teachers'  College,  New  York.  Even  after  years  of 
experience  and  the  most  painstaking  work,  the  instruction  often  reflects  the 
limited  background  of  the  teachers.  A  university  training  school  would  be 
of  high  value  in  providing  teachers  with  more  actual  information  as  well  as 
some  knowledge  of  methods  of  teaching. 

Thirdly,  the  university  training  school  will  fill  a  much  needed  place  in 
providing  the  training  essential  to  meet  the  demands  of  public  health  nurs- 
ing.    Here,  the  final  period  of  academic  study  would  include  case  work  and 


712  Hospital  and  Health  Survey 

the  many  phases  of  social  service,  without  a  knowledge  of  which  the  nurse's 
training  alone  cannot  fit  a  woman  for  acceptable  work  in  this  rapidly  develop- 
ing field. 

A  Shorter  Basic  Training  for  All  Nurses 

In  addition  to  training  for  advanced  work  the  university  should  assist  in 
providing  better  science  teaching  for  the  rank  and  file;  that  is,  for  students 
who  have  either  no  wish  or  no  ability  for  specializing  in  the  higher  branches 
of  nursing,  but  who  would  take  advantage  of  a  good  basic  nursing  training, 
especially  if  it  were  shorter  than  the  present  three-year  course.  Such  stu- 
dents would  obtain  in  the  university  the  training  in  the  preliminary  sciences; 
they  would,  under  a  plan  to  be  subsequently  worked  out  in  detail,  be  gradu- 
ated after  a  basic  training  of  about  two  years  and  four  months,  with  the 
diploma  of  nurse  but  without  a  university  degree.  Such  nurses  would  be 
available  primarily  for  bedside  care.  They  would  not  have  the  added 
training  and  experience  which  is  needed  to  fit  for  the  exacting  needs  of 
public  health  nursing  and  for  teaching  and  administrative  positions;  but  by 
a  reduction  of  the  present  three-years'  course,  the  bedside  nurses  would  be 
available  in  larger  numbers  and  help  to  meet  the  present  shortage. 

Such  a  shortening  of  the  course  would  be  possible  both  through  the  better 
teaching  in  the  college  and  also  through  the  elimination  of  non-educational 
housekeeping  duties  and  of  the  present  indefensible  repetition  of  services. 

It  will  be  noted  that  in  the  foregoing  discussion  no  definite  length  of 
time  has  been  proposed  either  for  the  full  university-hospital  course  oj"  for 
the  briefer  basic  training.  At  present  the  3-year  course  is  the  rule  and  a  5- 
year  course  has  been  suggested  for  the  central  university  school.  How  far 
these  courses  may  safely  be  reached  by  elimination  of  the  non-educational 
features  noted  above,  still  remains  to  be  determined. 

Studies  of  hospital  training  schools  in  other  cities,  of  which  the  Cleveland 
Survey  has  been  one,  are  now  ia  progress  by  the  Committee  on  Nursing 
Education.  From  detailed  observation  of  the  work  and  instruction  of  first, 
second  and  third  year  students  in  different  types  of  hospitals  a  composite 
picture  will  be  obtained  of  the  total  careers  of  students  and  the  training 
afforded  at  each  hospital.  This  study  will  aid  materially  in  determining 
how  the  present  course  may  be  reduced  without  sacrificing  any  of  the  essen- 
tial services.  Sufficient  time  has  not  yet  been  afforded  to  complete  these 
intensive  studies  on  which  will  be  based  our  ultimate  recommendations  for  a 
detailed  curriculum  for  both  types  of  university  students. 

RESULTS  OF  FIELD  STUDY 

It  is  obvious  that  no  general  statements  can  cover  the  Cleveland  training- 
schools  as  a  whole.  Their  procedures  naturally  differ  with  their  size,  their 
age,  financial  resources,  religious  affiliations,  etc.  The  results  of  our  field 
study  are  here  summarized  so  far  as  possible.  The  standing  of  the  hospitals 
is  shown  with  relation  to  the  standards  regarded  as  desirable  under  present 
conditions,  that  is,  while  students  are  still  used  to  staff  the  wards.     The  dis- 


Nursing  713 

cussion  falls  under  the  following  heads:  organization  of  the  training  school, 
minimum  entrance  requirements,  capacity  of  hospitals  and  services  offered, 
instruction,  conditions  of  work  and  living  conditions. 

ORGANIZATION  OF  THE  TRAINING  SCHOOL 

The  relationship  between  schools  of  nursing  and  hospitals  should  be 
essentially  the  same  as  that  created  between  medical  schools  and  hospitals. 
The  school  of  nursing,  like  the  medical  school,  exists  primarily  to  give  tech- 
nical education  to  students  who  are  to  obtain  part  of  their  training  in  the 
wards  of  the  hospital.  It  follows  necessarily  that  many  important  factors 
in  the  training  school  for  nurses  fall  wholly  outside  the  administrative  scheme 
of  a  hospital. 

(a).  The  best  organization  of  a  school  of  nursing  is  clearly  the  university 
organization,  in  which  ward  training  is  given  in  such  hospitals  as  come  up 
to  the  conditions  of  teaching  and  of  living  required  by  the  university  for  edu- 
cation of  its  students. 

(6).  Until  the  university  organization  is  formed  a  similar  arrangement 
might  be  effected  by  an  independent  board,  capable  of  directing  the  educa- 
tional policies  of  the  training  school,  which  could  contract  with  the  hospital 
to  give  the  necessary  ward  training  supplementing  the  laboratory  and  di- 
dactic teaching  supplied.  Among  the  Catholic  hospitals  or  in  hospitals 
administered  under  religious  organizations  which  have  no  Boards  of  Trustees 
or  which  are  subject  to  the  Bishop  of  the  Diocese,  an  advisory  committee 
might  be  established  at  once  to  direct  the  educational  policies  of  the  train- 
ing schools. 

(c).  In  such  hospitals  as  may  still  continue  to  keep  the  training  school 
as  part  of  the  hospital  organization,  there  should  be  appointed  by  the  Board 
of  Trustees  a  training  school  committee,  composed  of  both  men  and  women, 
to  direct  educational  policies.  This  committee  should  be  composed  of  rep- 
resentatives of  the  Board  of  Trustees  and  other  persons  known  to  have  had 
experience  in  education  and  also  members  of  the  alumnae  of  the  school. 
The  superintendent  of  the  hospital  and  the  director  of  the  training  school 
in  the  hospital  and  representatives  of  the  medical  staff  selected  by  the  medical 
executive  committee,  though  not  members  of  the  training  school  committee, 
should  sit  with  the  committee. 

The  superintendent  of  nursing  in  the  hospital  should  be  appointed  by  the 
Board  of  Trustees  of  the  hospital,  on  nomination  of  the  superintendent  of 
the  hospital,  with  the  concurrence  of  the  training  school  committee.  It  is 
considered  desirable  that  the  superintendent  of  the  hospital  should  delegate 
to  the  superintendent  of  the  training  school  the  appointment  and  dismissal 
of  nursing  personnel. 

The  offices  of  principal  of  the  training  school  and  superintendent  of 
nurses,  that  is  an  educational  and  administrative  office,  may  or  may  not  be 
combined  in  the  same  individual.  When  they  are  combined  the  head  of  the 
training  school  should  be  designated  "Superintendent  of  Nurses  and  Prin- 
cipal of  the  Training  School." 


714  Hospital  and  Health  Survey 

So  far  as  concerns  the  make-up  of  the  coniniittee,  in  Cleveland  only  one 
of  the  11  general  hospitals  studied  had  a  training  school  committee  approxi- 
mating the  desirable  form.*  This  hospital  is  St.  Luke's.  It  is  worthy  of 
note  that  the  committee  has  on  it  an  alumna  of  the  school  and  that  it  has 
taken  a  special  interest  in  providing,  so  far  as  is  possible  with  unsuitable 
buildings,  unusually  homelike  conditions  of  living  for  the  nurses. 

Some  variations  from  the  above  form  of  the  training  school  committee 
are  the  following: 

At  Lakeside  eight  of  the  twelve  members  are  women. 

At  Huron  Road  the  committee  consists  of  only  three  members,  all  of 
whom  are  attending  physicians.  One  is  also  a  member  of  the  Board  of 
Trustees,  and  one  is  an  instructor  at  Western  Reserve  University. 

None  of  the  ten  remaining  hospitals  has  a  training  school  committee. 

At  Mt.  Sinai  this  lack  may  in  part  account  for  the  fact  that  the  living 
conditions  for  the  students  and  the  equipment  in  class  rooms  and  labora- 
tories fail  to  come  up  to  the  high  standards  of  the  other  departments  of  this 
hospital. 

An  advisory  board  at  the  City  Hospital  has  recently  disbanded  and  the 
appointment  of  the  chairman  of  a  new  committee  was  at  the  time  of  the 
investigation  under  consideration  by  the  Director  of  Public  Welfare. 

None  of  the  Catholic  hospitals  has  a  training  school  committee;  nor 
has  Fairview.  Glenville,  or  Lakewood.  A  former  training  school  committee 
at  Fairview  has  recently  been  abandoned. 

Cost  Accounting 

An  adequate  system  of  cost  accounting  is  practically  unknown  in  train- 
ing schools.  Cleveland  is  no  exception  to  the  rule.  For  none  of  the  hos- 
pitals is  it  possible  to  state  the  per  capita  cost  of  student  nurses,  including 
maintenance  as  well  as  instruction.  Xor  on  the  other  hand,  is  it  possible 
to  state  the  financial  value  of  work  done  by  the  students  and  staff  and  the 
saving  to  hospitals  from  the  utilization  of  their  services. 

Money  Allowance  to  Students 

The  once  prevalent  custom  of  paying  students  a  small  yearly  sum  during 
training  is  gradually  beins;  abandoned.  To  attract  students  of  good  calibre, 
it  is  clearly  more  desirable  to  devote  such  funds  to  improving  the  course  of 
training.  Better  teaching,  equipment  and  living  conditions  are  a  greater 
attraction  for  desirable  students  than  a  small  financial  inducement.  In- 
deed, some  hospitals  instead  of  paying  their  students  are  charging  a  small 
fee  for  instruction. 

In  Cleveland  the  old  custom  of  paying  students  exists  in  all  but  two 
hospitals,  Lakeside  and  St.  Luke's.  Even  in  these,  the  system  still  prevails 
in  the  custom  of  providing  uniforms  and  textbooks. 

"The  two  spec'al  hospitals,  Cleveland  Maternity  and  St.  Ann's,  are  omitted  in  this  section. 


Xtksixc  71 5 

MINIMUM  ENTRANCE  REQUIREMENTS 

The  Ohio  state  law  requires  that  students  be  at  least  18  years  of  age  when 
they  enter  the  training  school.  Most  of  the  Cleveland  training  schools  do 
not  go  beyond  this  requirement,  but  four,  Huron  Road,  Lakeside,  ;  Lake- 
wood  and  St.  Luke's,  make  19  the  minimum  age  for  entrance.  In  four  schools 
a  few  students  under  18  had  at  the  time  of  our  investigation,  been  accepted; 
at  the  City  Hospital,  there  were  2  who  entered  under  age,  at  Fairview  3,  at 
St.  Alexis  2,  and  at  St.  Vincent's  3. 

The  age  at  entrance  of  459  students  in  9  hospitals  was  obtained  and 
showed  that  in  all  but  3  of  these  hospitals,  the  median  age  at  entrance  was 
"20  or  over. 


Age  at  Entrance* 


Huron  Road 

Lakeside 

St.  Vincent's .......... 

Glenville 

Mt   Sinai ■.'.'. 

St.  John's... 

Cleveland  City 

Fairview .. 

St.  Alexis 

*  Data  on  this  point  were  not  obtained  from  Lakewood  and  St.  Luke's. 

f  That  is,  ranging  all  the  ages  from  highest  to  lowest,  the  median  is  the  age  of  the  student  in  the  middle  . 

Minimum  Educational  Requirement 

According  to  the  Ohio  law,  the  minimum  educational  requirement  for 
entrance  into  the  training  school  is  completion  of  one  year  of  high  school. 

Of  the  11  hospitals  considered  in  this  connection,  4  (Huron  Road,  Lake- 
side, Mt.  Sinai  and  St.  Luke's)  require  graduation  from  high  school  for  en- 
trance. At  St.  Luke's  this  requirement  has  just  been  put  into  effect,  and 
the  first  class  entering  under  the  new  regulation  is  made  up  entirely  of  high 
school  graduates.  In  the  other  three  schools,  the  requirement  is  of  longer 
standing,  and  all  three  make  exceptions  to  the  rule,  as  is  shown  in  the  fol- 
lowing table. 

The  personal  histories  of  528  students  in  11  hospitals  were  obtained 
and  showed  that  347,  or  65%,  had  completed  four  years  of  high  school,  as 
follows : 


Age  Required 

Median  Agef 

19 

22 

19 

22 

18 

21 

18 

20 

18 

20 

18 

20 

18 

19 

18 

19 

18 

18 

716  Hospital  and  Health  Survey 

Education  at  Entrance 

Total  No.  No.  with  4  years  of 

of  Students*  High  School  or  more      Percent 

Lakeside 133  125  93 

Mt.  Sinai 64  60  93 

St.  Luke's 59  50  84 

Huron  Road 33  26  78 

Cleveland  City 63  33  52 

Fairview 24  12  50 

St  John's 30  11  36 

St.  Alexis 9  3  33 

St.  Vincent's 78  20  25 

Glenville 22  5  22 

Lakewood 13  2  15 

Total 528  347  65 

Exclusive  of  the  three  Catholic  training  schools,  St.  John's,  St.  Alexis 
and  St.  Vincent's,  and  the  3  smallest  training  schools  remaining,  Fairview, 
Glenville  and  Lakewood  (which,  as  is  later  suggested,  might  well  combine 
in  giving  theoretical  instruction  to  their  students),  the  percentage  of  students 
qualified  for  college  entrance  is  83%. 

*  In  a  few  hospitals  data  is  not  available  for  one  or  two  students. 

CAPACITY  OF  HOSPITALS  AND  SERVICES  OFFERED 

Desirable  Standards 

To  qualify  as  fitted  to  give  an  adequate  training  of  nurses,  a  hospital 
should  provide  the  requisite  number  of  patients  and  variety  of  suitable 
services.  According  to  the  standard,  a  general  hospital  under  municipal 
or  private  endowment,  neither  too  large  nor  too  small,  is  best  fitted  for  this 
need.  As  a  teaching  field  the  general  hospital  of  400  to  500  beds  is  held  to 
rank  first,  if  it  gives  not  only  the  four  main  branches— medical,  surgical, 
children's  and  obstetrics — but  certain  special  branches,  such  as  communi- 
cable diseases,  mental  and  nervous  disorders,  etc. 

If  all  of  these  branches  are  not  included  in  the  clinical  resources  of  the 
hospital,  they  should  be  made  available  for  the  students  through  affiliation 
with  other  hospitals. 

Hospitals  of  more  than  500  beds,  while  they  frequently  offer  a  richer 
variety  and  number  of  services,  labor  under  greater  difficulties  in  the  way 
of  securing  adequate  supervision  and  instruction  of  the  students. 

Hospitals  having  less  than  400  but  more  than  150  beds  also  offer  excellent 
teaching  facilities.  Those  of  less  than  about  50  beds  cannot  maintain  schools 
of  accepted  standards. 


N'UBSIH  G  717 

Findings 

1.  Hospitals  of  More  than  400  Beds 

The  City  Hospital 

In  Cleveland  the  only  hospital  of  more  than  400  beds  is  the  City  Hos- 
pital with  781,  of  which  481  beds  are  utilized  for  training.  The  difficulties 
of  securing  adequate  supervision  for  so  large  an  institution  have  here  been 
increased  by  the  insufficiency  of  the  nursing  staff  for  actual  care  of  the  sick. 
The  shortage  of  students  and  of  proper  ward  help  has  led  to  the  diversion 
of  graduate  nurses  to  routine  care  of  patients  from  their  primary  duty  of 
supervision  and  instruction  of  students. 

Thus,  for  example,  the  graduate  nurse  responsible  for  the  supervision  of 
students  having  training  in  the  children's  wards  of  40  beds,  had  only  2  stu- 
dents and  1  attendant  for  the  care  of  these  patients.  In  addition  she  was 
also  head  nurse  in  the  adjoining  temporary  influenza  ward  of  23  beds,  where 
she  had  only  1  student  and  an  attendant  to  assist  her.  In  this  emergency, 
the  Superintendent  of  Nurses  was  trying  to  secure  another  graduate  for  the 
influenza  ward,  which  had  just  been  opened. 

Supervision  and  instruction  were  clearly  impossible;  the  first  object  was 
necessarily  to  care  for  the  patients  as  well  as  difficult  conditions  permitted. 
Faulty  technic  on  the  part  of  the  students  was  observed  and  under  the 
circumstances  could  hardly  have  failed  to  occur. 


(a).  Clinical  Opportunities 

In  its  clinical  opportunities,  this  hospital  offers  an  unusually  wide  range 
of  experience.  In  contrast  to  all  the  other  Cleveland  hospitals,  it  offers 
an  extensive  and  acute  medical  service  with  definite  segregation  of  chronics 
and  a  particularly  adequate  field  for  training  in  pediatrics  and  communi- 
cable diseases,  including  venereal  disease. 

The  training  school,  however,  is  not  able  to  make  the  most  of  these 
clinical  opportunities.  The  medical,  surgical,  obstetrical  and  children's  ser- 
vices are  inadequately  staffed,  poorly  equipped,  badly  housed  in  the  gloomy 
old  main  building,-  and  have  been  allowed  to  become  run-down  and  below 
standard. 

The  contagious  and  venereal  disease  services,  on  the  other  hand,  might 
well  be  further  developed  to  afford  opportunities  for  affiliation  for  students 
from  other  hospitals. 

The  contagious  disease  service  is  in  a  new  building  with  modern  pro- 
visions for  the  efficient  care  of  patients  and  consequent  good  training  of 
students.  Moreover,  supervision  is  good  and  theoretical  instruction  is  given 
at  the  same  time  with  the  practical  experience  on  the  wards,  so  that  the  two 
can  be  properly  correlated.  Commendable  precautions  are  taken  to  protect 
the  students  from  infection  and  to  prevent  them  from  carrying  it  to  others. 
For  this  purpose  the  hospital  is  exceptionally  well  equipped. 


718  Hospital  and  Health  Survey 

This  department  is  necessarily  more  fully  staffed  than  other  depart- 
ments, even  at  their  expense.  The  pupil  nurse  service  is  supplemented  by 
affiliating  students  from  two  other  hospitals.  That  the  exceptional  oppor- 
tunities for  training  are  appreciated  by  the  students  is  evident  from  a  comment 
from  the  superintendent  of  Glenville  Hospital,  one  of  the  affiliating  schools 
afterward  visited.  "This  service  is  an  elective  one  for  senior  students. 
So  fa/  all  senior  students  have  asked  for  it,  and  on  return  here  comment 
most  enthusiastically  on  their  experience. " 

Other  Cleveland  schools  of  nursing  might  well  take  advantage  of  affilia- 
tion with  this  contagious  hospital,  thus  securing  a  much  needed  experience 
for  their  students.  Such  affiliations  would  also  release  a  certain  number  of 
City  Hospital  students  for  the  other  services  there,  as  the  four  to  six  months 
of  contagious  disease  experience  required  of  them  at  present  could  be  shortened 
if  an  adequate  nursing  service  in  this  department  were  otherwise  provided. 

In  the  specific  (venereal  disease)  wards,  also,  more  favorable  conditions 
for  training  are  noted,  and  valuable  experience  for  the  student  is  found  here, 
especially  in  the  Women's  Department,  which  includes  12  beds  for  obstetrics 
complicated  by  venereal  disease.  The  capacity  of  the  venereal  disease 
wards  is  50  men,  42  women  and  8  children,  and  the  building  has  recently 
been  renovated  to  meet  the  demands  of  the  service.  The  training  possibili- 
ties are  good  and  affiliation  could  well  be  arranged  for  students  from  other 
schools  wishing  to  include  this  experience  in  their  preparation  for  the  public- 
health  field,  or  even  in  their  general  training.  Such  an  arrangement  would 
help  to  remedy  the  insufficiency  of  the  nursing  staff  at  present,  which  makes 
it  impossible  for  the  nursing  duties  to  be  properly  organized. 

The  buildings  for  the  tuberculosis  service  and  the  chronic  patient  ser- 
vice in  which  the  nervous  and  mental  cases  are  housed,  although  they  might 
afford  valuable  clinical  oportunities,  cannot  offer  adequate  training  until 
radical  changes  have  been  made. 

2.  Hospitals  of  Between  290  and  140  Beds 

The  second  group  of  hospitals  considered  have  the  following  number 
of  beds. 

St.  Vincent's : 290 

Lakeside 289 

Mt.  Sinai 255 

St.  Alexis 250 

St.  John's 158 

St.  Luke's 140 

While  these  hospitals  offer  a  sufficient  number  of  beds  to  comply  with 
the  recommendations  for  a  good  teaching  field  for  nurses,  a  consideration  of 
the  variety  of  services  provided  is  also  needed  in  order  to  gauge  their  ade- 
quacy for  the  purposes  of  training. 


Nursing  719 

(a).  Predominance  of  the  Surgical  Services 

In  the  main,  the  outstanding  fact  is  the  inadequacy  of  the  medical  ser- 
vices and  the  specialties,  broadly  speaking,  on  the  one  hand,  and  on  the  other 
the  predominating  claims  of  the  surgical  services,  at  the  expense  of  the  for- 
mer. The  predominance  of  surgical  services  is  the  natural  result  of  the  in- 
sufficient number  of  hospital  beds,  the  emergencies  of  surgical  need  taking 
precedence  of  medical  needs,  and  the  added  fact  that  a  higher  proportion  of 
surgical  cases  than  of  medical  require  hospital  care.  The  predominance  of 
surgical  services  obviously  makes  for  a  badly  balanced  scheme  of  instruc- 
tion. It  is  plainly  impossible  to  give  a  well-rounded  nursing  education 
when  so  large  a  proportion  of  the  student  nurses'  time  is  absorbed  in  purely 
surgical  or  predominatingly  surgical  work.  This  lack  of  proportion  is 
amply  illustrated  in  the  records  of  practical  experience  of  individual  students 
at  various  hospitals. 

Number  of  Beds  and  Percentage  of  Admissions 

The  most  obvious  evidence  of  the  extent  to  which  surgical  training 
dominates  other  services  lies  in  the  proportion  of  beds  assigned  to  each  and 
in  the  percentage  of  admissions. 

At  Lakeside  there  are  85  surgical  beds  to  61  medical;  St.  Alexis  has  124 
surgical  to  50  medical;  St.  John's  89  surgical  to  29  medical;  St.  Luke's  56 
surgical  to  36  medical;  St.  Vincent's  123  surgical  to  42  medical.  At  St. 
Alexis,  on  the  day  this  hospital  was  visited,  of  the  25  beds  in  the  women's 
medical  department,  17  or  over  two-thirds,  were  occupied  by  surgical  cases. 
At  Mt.  Sinai  an  even  proportion  is  maintained,  namely  47  surgical  beds  to 
46  medical. 

Analysis  of  the  available  figures  showing  the  admissions  for  two  hospitals 
indicates  still  more  clearly  the  extent  to  which  Cleveland  hospitals  are  given 
over  to  surgical  cases.  At  Lakeside  in  the  year  1918  surgical  admissions 
were  3,388  as  contrasted  with  1,819  medical,  and  in  1916  (that  is,  when  the 
entire  surgical  staff  was  available),  there  were  4,160  surgical  admissions  as 
against  1,498  medical.  The  latter  figure  included  admissions  in  pediatrics. 
At  St.  Luke's  the  record  of  admissions  for  1919  shows  that  25%  of  the  cases 
were  medical  as  against  55%  surgical. 

Number  of  Days  Spent  in  Surgical  Services 

The  bearing  of  these  facts  on  the  nurses'  training  is  shown  by  the  record 
of  their  actual  days  spent  in  surgical  services. 

Thus,  from  a  study  of  the  records  at  Lakeside  it  was  found  that  of  17 
seniors  who  had  been  in  the  hospital  2  years  and  9  months,  12  had  already 
had  from  7  to  10  months'  training  in  the  surgical  wards  and  operating  room, 
though  the  time  planned  for  these  services  is  6  months.  Of  the  remaining 
five,  3  had  had  6  months,  1  had  had  5  months,  and  1  had  had  4  months  in 
these  services.  When  gynecological  and  gauze  room  experience  is  added, 
as  well  as  75%  of  the  time  spent  in  private  service,  which  may  legitimately 
be  reckoned  as  surgical,  these  17  seniors  had  spent  from  14  to  19  months 
in  the  various  surgical  services. 


720  Hospital  and  Health  Survey 

In  contrast  to  the  time  spent  in  the  surgical  wards  and  operating  room 
(ranging  from  5  to  10  months)  is  the  time  spent  by  these  17  seniors  on  med- 
ical wards,  ranging  from  a  little  less  than  2  months  to  6  months.  The 
median  *  is  about  three  months  and  three  weeks  as  against  a  median  of  seven 
months  in  general  surgical  experience. 

At  St.  Luke's,  6  seniors,  who  had  been  in  training  from  2^2  to  2%  years, 
had  spent  from  6  to  13  months  in  surgical  services.  This  does  not  include 
the  months  spent'  in  the  private  service,  a  large  proportion  of  which  is  sur- 
gical. 

These  same  students  had  spent  from  4  to  8  months  in  the  medical  wards, 
the  median  being  between  5  and  6  months  as  against  a  median  between  9  and 
10  months  in  surgical  experience. 

The  actual  experience  of  12  seniors  at  St.  Vincent's  shows  a  similar  dis- 
proportion. With  two  exceptions,  these  students  had  not  yet  completed 
~3^  years  of  their  training,  and  yet  already  3  had  had  9  months,  1  had  had 
10  months,  4  had  had  12  months,  3  had  had  13  months  and  1  had  had  14 
months  in  the  various  surgical  services. 

The  medical  experience  of  these  same  students  ranged  from  4^  to  834 
months,  the  median  being  a  little  less  than  6  months  (174-177  days)  as  against 
a  median  of  12  months  in  surgical  service. 

That  it  is  not  impossible  to  approximate  more  nearly  the  program  of 
services  planned  is  proved  by  the  example  of  Mt.  Sinai.  This  hospital  is 
more  successful  than  any  other  in  this  group,  in  keeping  the  surgical  experience 
to  the  specified  time,  even  though  the  time  planned  is  somewhat  long.  Six 
months  each  are  allowed  to  medical  nursing  and  surgical  nursing,  including 
nursing  of  private  patients. 

The  records  of  7  seniors,  who  had  been  in  training  34  months  or  over, 
showed  that  in  surgical  service  in  the  wards,  the  students  spent  from  3 
months  to  a  little  more  than  5  (160  days);  the  median  is  4^2  months.  In 
medical  ward  service,  the  7  students  spent  from  23^  to  7  months,  the  median 
being  nearly  6  months  (171  days).  On  private  duty,  the  students  had 
spent  from  a  month  and  3  weeks  to  5  months,  the  median  being  a  little  more 
than  33/2  months  (107  days). 

As  private  duty  is  for  the  most  part  largely  surgical,  it  is  reasonable  to 
conclude  that  at  this  hospital  surgical  service,  which  on  the  wards  was 
slightly  below  the  time  planned,  is  supplemented  by  the  private  surgical 
duty,  and  the  medical  service,  which  in  the  wards  approximates  the  6  months 
planned,  i*  not  unduly  prolonged  by  the  private  duty. 

In  the  operating  room  all  seven  seniors  under  discussion  exceeded  the  2 
months  planned  for  this  service.  Two  of  these  students,  however,  were 
specializing,  and  their  time  was  purposely  prolonged.  Only  one  of  the 
remaining  five  overstayed  the  time  planned  by  as  much  as  one  month;  the 
other  four  exceeded  the  time  by  one  to  two  weeks. 

*  That  is,  ranging  all  the  months  from  highest  to  lowest,  the  median  is  the  figure  showing  the  middle 
number  of  months. 


Nursing  721 

From  this  summary,  it  appears  that  with  the  exception  of  Mt.  Sinai  the 
tendency  is  to  devote  at  least  twice  as  much  time  to  surgical  training  as  to 
medical* 

(6).  General  Inadequacy  of  the  Medical  Service  for  Training 

This  inadequacy  is  due  to  two  causes,  the  predominance  of  the  surgical 
services,  and  the  large  proportion  of  chronics.  The  predominance  of  the 
surgical  services  and  the  consequent  curtailment  of  training  in  the  medical 
service,  has  been  dealt  with  above.  The  proportion  of  chronics  in  the 
medical  wards  visited  ranged  from  40%  to  58%  in  the  three  hospitals  in  which 
this  condition  was  observed.  At  Lakeside,  on  the  day  when  the  medical 
wards  were  visited,  8  of  the  19  patients  on  the  men's  ward,  and  4  of  the  11 
patients  on  the  women's  ward  were  chronics.  In  order  to  make  the  most 
of  the  inadequate  medical  service  for  teaching,  the  students  at  Lakeside  are, 
by  an  excellent  practice,  required  to  hand  in  written  case  reports  while  on 
duty  in  the  medical  wards. 

At  St.  John's,  on  the  floor  assigned  to  medical  cases,  24  were  under  treat- 
ment on  the  day  of  the  inspection.  Of  these  14  were  chronics  and  2  were 
surgical  cases.  At  St.  Vincent's  there  wrere  14  patients  in  the  women's 
medical  ward,  of  whom  6  were  chronics,  two  of  them  in  reality  boarders  of 
several  years'  standing.  At  Mt.  Sinai  and  St.  Luke's  no  data  on  this  point 
were  obtained.  At  St.  Alexis  chronics  are  segregated  on  a  special  floor. 
But  in  this  hospital,  owing  to  the  lack  of  graduate  nurses,  training  is  given 
in  the  women's  wards  only,  so  that  students  receive  no  experience  either 
medical  or  surgical,  in  the  nursing  of  men  patients. 

(c).  Communicable  Diseases 

At  the  time  of  the  investigation,  none  of  the  hospitals  in  this  group  pro- 
vided any  experience  whatsoever  in  communicable  disease,  except  for  occa- 
sional cases  which  develop  in  the  hospital  and  cannot  be  transferred.  This 
failure  is  all  the  more  striking,  owing  to  the  rare  opportunities  for  training 
in  communicable  disease  offered  at  the  City  Hospital,  of  which  the  small 
hospital  of  Glenville,  for  instance,  has  taken  advantage. 

id).  Pediatrics 

Only  two  hospitals  of  this  group,  Lakeside  and  Mt.  Sinai,  have  an  ade- 
quate number  of  beds  for  training  in  this  branch.  The  other  four  hospitals 
either  provide  no  beds  for  this  service,  or  provide  a  very  small  number, 
which  are  almost  all  used  for  surgical  cases  and  thus  afford  no  training  in 
pediatrics  proper. 

(e).  Obstetrics 

Of  the  six  hospitals  under  discussion,  three  offer  obstetrical  training  within 
their  own  wards.  These  are  Mt.  Sinai,  St.  John's  and  St.  Luke's.  Except 
at  St.  Luke's,  no  provision  is  made  for  out-patient  obstetrical  training,  the 
student  nurses  thus  failing  to  obtain  experience  in  outside  prenatal  work,  or 

*  Records  of  actual  experience  were  not  available  for  students  at  St.  A'exis  and  St.  John's.  From 
the  assign -nent  of  beds,  it  is  evident  that  in  these  hospitals,  as  in  St.  Vincent's,  at  least  two-thirds  of  the 
entire  hospital  service  is  surgical. 


T^  Hospital  and  Health  Survey 

in  caring  for  patients  id  their  homes.  At  Mt.  Sinai  there  is  a  large  out-patient 
prenatal  clinic,  but  students  are  not  assigned  to  work  in  the  district.  The 
follow-up  work  there  is  done  by  the  social  service  department.  A  few  stu- 
dents, who  elect  public  health  work,  may  have  prenatal  experience  in  the 
University  District.  At  St.  Luke's,  student  nurses  have  training  in  all. three 
branches  of  obstetrical  work,  prenatal,  partum,  and  post-partum. 

Lakeside  and  St.  Vincent's  provide  obstetrical  training  through  affilia- 
tion, the  former  at  the  Cleveland  Maternity,  and  the  latter  at  St.  Ann's. 
The  Cleveland  Maternity  affords  training  both  on  the  wards  and  in  the  dis- 
trict, but  Lakeside  did  not,  at  the  time  of  the  investigation,  avail  itself  of  the 
outside  prenatal  and  partum  experience  for  its  students.  Moreover,  the 
type  of  supervision  for  student  nurses  given  by  the  Cleveland  Maternity  .is 
inadequate  and  scarcely  up  to  the  standards  of  modern  public  health  work. 
Students  from  St.  Vincent's  have  no  opportunity  for  out-patient  work. 

The  sixth  hospital  in  the  group  under  discussion,  St.  Alexis,  has  at  present 
no  obstetrical  training  either  within  its  own  wards  or  by  affiliation. 

(f).  Xenons  and  Mental  Diseases 

Except  for  occasional  cases,  these  hospitals  offer  no  experience  in  the  care 
of  patients  suffering  from  nervous  and  mental  diseases,  nor  is  there  indeed 
any  opportunity  for  offering  such  training  to  students.  At  the  City  Hospital 
there  is  a  large  group  of  mental  cases,  which  should  afford  a  desirable  field 
for  training.  But  the  absence  of  any  modern  methods  of  treatment  makes 
this  impossible  at  present.  In  contrast  to  the  now  accepted  methods  of 
treatment  in  enlightened  institutions,  patients  are  under  close  confinement 
and  practically  in  custodial  care  in  gloomy  cell-like  rooms. 

(q).  Private  Service    • 

The  public  wards  are  the  best  training  ground  for  student  nurses,  and 
by  far  the  greater  proportion  of  their  time  should  be  spent  there. 

It  has  been  suggested  that  the  ratio  of  private  to  free  beds  should 
not  exceed  one  to  four  in  hospitals  which  train  nurses.  Two  of  the  hos- 
pitals in  this  group,  Lakeside  and  St.  Vincent's,  have  a  ratio  nearly  twice  as 
high  as  is  considered  desirable,  the  ratio  in  each  case  being  1 :2.7.  The  ratio 
at  Mt.  Sinai  is  1:5.5;  at  St.  Luke's  1:4;  at  St.  Alexis  1:3.9  (exclusive  of  feeds 
on  the  floor  used  for  chronics);  at  St.  John's  1:3.7. 

Mt.  Sinai  follows  the  excellent  practice  of  relying  mainly  on  graduate 
nurses  for  the  staffing  of  the  private  rooms. 

The  days  spent  in  private  service  by  students  at  Lakeside  range  from  87 
to  306,  the  median  being  195  days,  or  slightly  over  six  months.  The  time 
planned  for  the  service  at  Lakeside  is  four  months.  At  St.  Luke's  the  range 
is  from  131  to  210,  and  the  median  between  140  arid  155  days.  At  Mt.  Sinai, 
the  range  is  from  53  to  149  days,  with  the  median  107  days,  about  three 
months  less  than  the  median  at  Lakeside,  and  a  month  less  than  at  St.  Luke's. 

Information  as  to  the  time  actually  spent  by  students  in  private  service 
whs  not  obtained  from  St.  Alexis,  St.  John's  and  St.  Vincent's  Charity.     St. 


N  Vs  ft  sing.    ■  723 

Vincent's  Charity  plans  that  each  student  shall  devote  six  months  to  private 
duty  nursing.  It  is  apparent  that  undue  emphasis  on  the  private  service 
constitutes  a  distinct  weakness  in  the  training  at  Lakeside  and  St.  Vincent's 
Charity  and  the  same  tendency  is  noticeable  at  St.  Luke's. 

3.  Hospitals  of  Between  140  and  50  Beds 

:Exclusive  of  Cleveland  Maternity  (61  beds)  and  St.  Ann's  Maternity 
(55  beds),  to  which,  as  special  hospitals,  these  standaids  do  not  apply,  there 
remain  four  smaller  general  hospitals.  These  can  provide  the  necessary 
variety  of  services  only  by  affiliation  with  larger  institutions.     These  are: 

Fairview ': 100  beds 

Huron  Road 87     " 

Glenville 70    " 

Lakewood :.' 53>    " 

The  medical  service  in  all  four  hospitals  is  limited  and  affords  but  meagre 
training  for  nurses.  In  fact,  it  appears  that  the  only  services  adequate  for 
nurses'  training  are  surgery  and  obstetrics.  Even  in  the  surgical  service, 
little  or  no  experience  is  afforded  in  such  important  branches  as  orthopedics 
and  diseases  of  the  eye  and  ear.  In  obstetrics  also,  training  is  limited. 
With  the  exception  of  the  Huron  Road  students,  who  affiliate  at  Cleveland 
Maternity,  the  service  is  entirely  lacking  in  partum  and  post-partum  care  in 
the  homes.  Students  at  Glenville  and  Huron  Road  receive  prenatal  train- 
ing in  the  University  Health  District.  Lakewood  and  Fairview  students  do 
not  get  this  experience.  In  all  four  hospitals  too  large  a  proportion  of  the 
training  is  in  the  private  service. 

For,  medical,  communicable,  nervous  and  mental  diseases,  as  well  as  for 
pediatrics,  all  of  the  hospitals  of  this  group  need  affiliation,  to  give  adequate 
training.  Glenville  makes  an  excellent  beginning  by  requiring  four  months' 
affiliation  in  pediatrics  and  providing  elective  courses  in  communicable 
diseases,  both  of  these  at  the  City  Hospital.  Glenville  was  at  the  time  of 
the  investigation  the  only  hospital  in  Cleveland  to  recognize  and  take  ad- 
vantage of  the  unusual  clinical  facilities  offered  there.  The  other  three 
hospitals  in  this  group  do  not  make  good  then"  own  deficiencies  by  any  such 
affiliations,  thus  failing  to  recognize  the  primary  importance  of  these  services 
in  the  nurses'  training. 

4    Out-Patient  Departments  . 

''Of- the  11  general  hospitals,  5  have  no  out-patient  department.  Of  the 
6  remaining  institutions,  Mt.  Sinai  offers  the  most  complete  opportunity  for 
training,  as  almost  all  the  services  are  represented  in  active  clinics.  Lake- 
side, records  show  a  higher  daily  average  of,  patient  attendance  than  Mt. 
Sinai,  but  Lakeside  lacks  prenatal  and  dental  service.  St.  Vincent's  Charity 
lacks  pediatric,  orthopedic,  prenatal  and  dental  services.  The  work  at  St. 
Lyke's  is  reported  to  be  "that  of  a  specialized  industrial  clinic  with  chiefly 
surgical  interests. "  The  medical  clinic  is  small  and  an  eye,  ear,  nose  and 
throat    clinic  has  just  been  started.     There  are,  however,  active   prenatal 


5524  Hospital  and  Health  Survey 

and  gynecological  clinics  where  students  may  receive  valuable  training. 
The  Huron  Road  dispensary  is  given  over  almost  entirely  to  surgical  cases; 
medical  cases  are  only  occasional.  The  City  Hospital  has  a  weekly  dental 
clinic,  which  is  very  active,  but  there  is  no  other  dispensary  service. 

Since  a  detailed  report  has  been  made  on  the  organization  and  work  of 
the  Cleveland  dispensaries,  they  are  not  further  treated  in  this  report.  None 
of  them  are  fully  utilized  as  teaching  fields  for  student  nurses.  Likewise 
social  service  departments  are  not  treated  here,  since  a  special  study  has 
been  made  of  the  work  of  these  departments. 

5.  Public  Health  Nursing 

At  present  a  very  small  number  of  students  take  advantage  of  the  ex- 
ceptional training  for  public  health  work  offered  in  the  University  Teaching 
District.  In  this  District,  Cleveland  has  made  a  distinct  contribution 
of  the  highest  grade  to  the  development  of  generalized  city  nursing.  In  no 
city  is  a  better  opportunity  afforded  for  training  and  supervision  in  such 
work,  if  sufficient  time  is  given  to  take  advantage  of  it 

Two  months  of  this  training  are  now  allowed  by  five  hospitals.  The 
course  is  elective  at  City,  Lakeside  and  St.  Luke's.  It  is  required  at  Glen- 
ville  and  Huron  Road.  Mt.  Sinai  allows  four  months  of  training  in  the  Uni- 
versity Teaching  District,  but  the  course  is  available  for  only  three  or  four 
students  each  year.  At  City  also  it  is  possible  to  elect  a  four  months'  train- 
ing in  the  District. 

INSTRUCTION 
Teaching  of  Nursing  Procedures 

Demonstration  Room 
A  special  room  for  the  teaching  of  nursing  procedures  is  provided  at  seven 
of  the  eleven  hospitals  considered  in  this  section.*  At  St.  Vincent's,  how- 
ever, the  room  was  not  in  use  at  the  time  of  the  investigation.  At  Glenville, 
Huron  Road,  St.  Ann's  and  St.  Luke's  the  same  class  room  is  used  for  nurs- 
ing procedures  that  is  used  for  other  subjects. 

At  Lakeside  and  City  the  class  room  is  large;  at  Mt.  Sinai  it  is  adequate; 
at  Glenville  it  is  small.  At  the  others  the  room  is  fair  as  to  size.  The  room 
at  St.  Ann's  is  crowded  with  material  used  in  connection  with  the  lecture 
courses. 

At  only  three  hospitals  is  the  demonstration  room  equipped  with  running 
water  and  gas  or  electric  stoves.  These  three  are  Glenville,  Lakewood,  and 
Mt.  Sinai.  At  the  City  there  is  a  stove  but  no  running  water;  at  Fairview 
and  St.  Luke's  there  is  running  water  but  no  stove.  .  The  other  hospitals 
rely  on  facilities  in  adjacent  rooms. 

All  the  rooms  are  supplied  with  material  sufficient  for  demonstration, 
though  there  are  special  difficulties  in  hospitals  which  have  no  special  room. 
At  Huron  Road  a  bed  is  brought  in  when  needed.  At  St.  Ann's  material 
for  demonstration  is  said  to  be  brought  from  the  wards  when  needed.  At 
St.  Luke's  the  material  is  brought  over  from  the  hospital  by  the  instructor. 

*  Information  on  most  of  these  points  was  not  obtained  from  St.  Alexis  and  Cleveland  Maternity 
Hospitals. 


Nursing  725 

At  only  two  hospitals  is  the  demonstration  room  supplied  with  material 
sufficient  for  practice  by  individual  students.  These  hospitals  are  Fairview 
and  Mt.  Sinai. 

Methods  of  Teaching 

With  the  exception  of  St.  Vincent's,  where  students  were  being  taught 
entirely  on  the  wards  at  the  tims  of  the  inspection,  there  is  class  room  in- 
struction in  the  theory  and  practice  of  nursing  in  all  eleven  training  schools. 

All  are  supplied  with  a  Chase  doll  for  demonstration.  In  addition, 
students  are  used  for  demonstration  except  at  St.  Ann's,  St.  John's,  and  St. 
Luke's. *  At  Lakeside,  patients  are  brought  over  from  the  wards  as  sub- 
jects for  the  demonstration  of  some  procedures,  especially  for  such  proced- 
ures as  bathing  and  hair-washing.  Patients  serve  as  subjects  at  Glenville 
occasionally,  and  at  Fairview  also  patients  are  occasionally  used,  but  only 
in  the  wards. 

Practice  in  the  Class  Room 

Special  periods  for  practice  in  the  demonstration  room  are  assigned  at 
Huron  Road  and  St.  John's.  At  Huron  Road,  a  practice  hour  of  1  hour 
daily  is  allowed,  except  on  Saturday.  At  St.  John's,  3  hours  of  practice  a 
week  is  required  of  probationers  and  1  hour  a  week  of  juniors  and  seniors, 
by  way  of  review. 

At  Fairview,  City,  and  Lakeside,  no  special  period  is  assigned,  but  part 
of  the  demonstration  period  is  used  for  practice  by  individual  students.  At 
Mt.  Sinai  the  study  hour  is  frequently  used  for  practice.  At  St.  Luke's 
there  is  no  opportunity  for  practice  between  classes,  as  the  room  is  in  use 
for  other  subjects  and  all  material  removed.  Glenville  and  St.  Ann's  like- 
wise make  no  provision  for  practice  in  the  class  room. 

Class  room  practice  is  supervised  by  the  instructor  in  the  six  hospitals 
which  make  any  provision  for  such  practice  of  procedures.! 

Hours 

The  hours  devoted  to  class  room  instruction  in  the  theory  and  practice 
of  nursing  by  Cleveland  training  schools  are  as  follows  :i 

St.  Luke's   170  hours 

Mt.  Sinai ..: 151 

Lakeside 120 

Lake  wood 120 

Huron  Road , 100 

St.  John's - 65 

City - 60 

St.  Vincent's 60 

Fairview 50 

Glenville 48 

*  At  Huron  Road  no  information  was  obtained  as  to  the  use  of  students  and  patients  as  subjects  for 
demonstration.  At  Lakewood  the  course  was  in  process  of  organization,  and  the  use  of  students  as  sub- 
jects was  planned. 

t  Supervised  practice  is  planned  at  Lakewood. 
Course  at  St.  Vincent's  not  given  at  time  of  inspection. 


726  Hospital  and  Health  Survey 

St.  Ann's  Maternity  Hospital  gives  10  hours  to  affiliating  students.  At 
Cleveland  Maternity  24  procedures  are  demonstrated  to  affiliating  students. 

Correlation   of   Theoretical   Work   with   Practical   Work   in    the 

Wards 

Obviously,  the  test  of  theoretical  instruction  in  nursing  is  its  application 
in  the  wards-.  The  teaching  of  practical  procedures,  to  be  fruitful,  must  be 
associated  not  only  with  demonstrations  and  practice  in  class,  but  with  close 
supervision  of  the  student's  work  in  the  wards  as  soon  as  possible  after  the 
class  work.  Without  such  close  correlation  of  theory  and  practice,  nursing 
technic  tends  to  be  lax  and  unintelligent. 

Example  of  Good  Correlation 

Of  the  thirteen  hospitals  in  Cleveland  a  high  standard  of  correlation  was 
found  only  at  one  hospital,  Mt.  Sinai.  Here  the  teaching  of  nursing  pro- 
cedures is  not  only  excellent  in  the  class  room,  but  is  followed  up  by  careful 
assignment  of  students  for  practice  in  the  wards  in  the  same  procedures 
which  they  have  just  learned  in  the  class  room,  with  thorough  supervision 
by.  the  instructor.  The  provision  of  standardized  equipment,  both  in  the 
class  room  and  in  the  wards,  has  been  a  very  considerable  factor  in  making 
possible  uniformity  of  nursing  procedures,  and  has  contributed  to  the  accu- 
rate technic  of  the  students  observed  in  the  wards. 

The  fact  that  students  are  not  hurried  when  on  duty  in  the  wardsj.but, 
owing  to  the  provision  of  ward  attendants,  labor-saving  devices  and  adequate 
equipment,  have  time  to  carry  out  the  procedures  exactly  as  taught,  also 
contributes  to  the  uniform  excellence  of  technic  observed. 

The  graduate  nurses  in  charge  of  wards  have  been  appointed  on  account 
of.  special  qualifications.  The  head  nurse  of  the  children's  ward  is  a  graduate 
of  the  Boston  Children's  Hospital;  the  head  nurse  of  the  obstetrical  ward 
has  had  postgraduate  training  at  the  Chicago  Lying-in  Hospital;  and  the 
nurse  in  charge  of  the  operating  room  is  a  graduate  of  St.  Mary's,  Rochester, 
Minnesota.  Thus  student  nurses  have  the  advantage  of  instruction. given 
by  specialists  in  their  own  departments.  .    .  ,; 

St.  Luke's  was  in  the  midst  of  reorganizing  its  instruction  at  the  time  of 
the  investigation,  but  already  had  developed  methods  which  should  result 
in  excellent  correlation.  For  example,  all  procedures  are  demonstrated  to 
the  head  nurses  in  the  class  room,  in  order  to  enlist  their  interest  and  co- 
operation in  the  teaching  of  students  and  to  insure  uniformity  of  method. 

Failure  to  Correlate  Theory  and  Practice 

The  varying  lack  of  success  in  correlating  theory  and  practice  in  nursing 
procedures  at  the  other  Cleveland  hospitals  is  due  to  different  causes. 

Lack  of  Equipment 

At  the  City  Hospital,  where  exceptionally  good  provision  is  made  for  class 
room  teaching,  the  entire  lack  of  many  essentials  in  ward  equipment  would 


Nursing  727 

make  it  impossible  to  exact  good  nursing  technic,  as  taught  in  the  elass 
room,  even  if  there  were  adequate  supervision  of  ward  practice. 

Lack  of  Organization 

At  Lakeside,  owing  to  other  required  duties,  the  instructor  of  prac- 
tical nursing  has  not  sufficient  time  to  supervise  adequately  even  the  proba- 
tioners on  the  wards.  Moreover,  no  provision  is  made  for  the  immediate 
application  of  class  room  teaching.  For  some  students  there  may  be  an 
interval  of  some  weeks  before  they  have  opportunity  to  put  their  class  room 
teaching  into  practice. 

Conflict  of  Teaching  with  Administrative  Duties 

At  four  other  hospitals,  Fairview,  Glenville,  St.  Alexis  and  Lakewood,  the 
teaching  of  practical  nursing  is  carried  by  the  superintendent  of  nurses  in 
addition  to  her  administrative  duties.  This  arrangement  obviously  does  not 
allow  enough  time  for  either  teaching  or  organized  supervision  of  nursing 
technic.  The  pressing  demands  of  purely  administrative  interests  continually 
thrust  into  the  background  the  apparently  less  immediate  needs  of  teaching. 

At  two  other  hospitals,  Huron  Road  and  St.  Vincent's,  a  somewhat 
similar  interference  with  proper  practical  teaching  is  found.  At  Huron  Road 
a  head  nurse  is  expected  to  give  the  class  room  and  practical  instruction  in 
nursing  procedure  while  her  primary  duty  is  management  of  a  ward  or  floor. 
At  St.  Vincent's,  the  supervisor  of  the  gynecological  and  women's  medical 
wards  was  the  instructor.  Obviously,  the  successful  combination  of. ..two 
such  functions  is  impossible. 

No  opportunity  was  presented  to  see  the  instruction  in  nursing  procedures 
at  St.  John's,  owing  to  the  illness  of  the  instructor  at  the  time  of  the  investi- 
gation. 

Instruction  at  the  Maternity  Hospitals  . 

The  remaining  hospitals,  Cleveland  Maternity  and  St.  Ann's  Maternity 
are  soecial  hospitals,  giving  obstetrical  training  to  second  and  third  year 
students,  and  to  students  of  advanced  standing.  In  the  case  of  these  stu- 
dents, acquaintance  with  nursing  procedures  is  presupposed,  except,  in  the 
special  field  of  obstetrics.  In  addition,  both  hospitals  offer  courses  of  15 
months  in  obstetrics  to  women  who  have  had  no  previous  training  in. nurs- 
ing. '  At  Cleveland  Maternity,  demonstrations,  supervision  and  instruction 
on. the  wards  are  given  by  graduate  nurses.  At  St.  Ann's,  the  teaching  and 
supervision  are  below  standard,  since  they  are  in  large  part  carried  out  by 
graduates  of  the  fifteen  months'  course  in  obstetrics  only. 

While  far-reaching  recommendations  have  been  presented  in  the  'section 
on  Prenatal  and  Maternity  Nursing  Service,  which  may  by  some  be  con- 
sidered as  implying  unjust  criticism  upon  the  quality  of  nursing  service  now 
given  by  the  Maternity  Hospital,  it  is  particularly  to  be  noted  that  it  is 
not  the  quality  of  professional  care  either  by  physicians  or  nurses  which  is 
criticised.  It  is  not  conceived  by  the  staff  of  the  Survey  that  among  the 
functions    of    a  university  teaching  hospital  is  the  administering  of  a  city- 


728  Hospital  and  Health  Survey 

wide  prenatal  service.  Lack  of  good  administrative  organization,  inadequacy 
of  supervision,  lack  of  continuity  of  the  present  nursing  service  for  maternity 
cases,  are  the  main  reasons  for  the  recommendations  that  the  Visiting  Nurse 
Association  and  not  the  Maternity  Hospital  assume  the  broader  functions 
proposed.  Without  the  initiative,  the  standards,  the  demonstrations  in 
this  field  made  by  the  Maternity  Hospital  medical  and  nursing  staff,  Cleve- 
land could  not  now  even  consider  such  a  thorough-going  program  of  maternity 
care  as  is  proposed.  Cleveland's  mothers  owe  much  to  the  Cleveland  Ma- 
ternity Hospital. 

Opportunities  for  Case  Study 

Case  study  is  required  of  student  nurses  only  at  Lakeside  and  Mt.  Sinai. 
At  Lakeside  this  good  feature  is  found  only  in  the  medical  wards. 

Teaching  of  the  Fundamental  Sciences* 

In  most  schools  of  nursing  instruction  in  the  fundamental  sciences  is 
weak,  owing  to  the  lack  of  good  teachers  and  of  equipment,  and  the  lack  of 
preparation  on  the  part  of  the  students.  Yet  the  employment  of  teachers 
is  in  itself  an  advance  over  former  methods  of  instruction. 

Most  hospitals  are  equipped  with  one  or  more  rooms  in  which  it  is  pos- 
sible for  students  to  gather  around  a  table,  view  specimens,  and  otherwise 
witness  a  demonstration  by  the  instructor,  of  the  principles  to  be  taught.  But 
this  is  not  real  laboratory  instruction,  which  should  provide  for  individual 
experiment  and  observation. 

None  of  the  eleven  general  hospitals  studied  in  Cleveland  is  prepared  to 
give  individual  laboratory  instruction  in  all  four  of  the  fundamental  science 
courses.  Details  of  the  equipment  provided  are  given  under  each  science 
course.  None  of  the  hospitals  makes  any  separate  allowance  for  laboratory 
supplies,  demonstration  material,  or  reference  library. 

Instructors  are  often  overtasked  with  administrative  duties.  The  teach- 
ing staff  at  Lakeside  is  materially  hampered  by  the  necessity  of  attending  to 
many  details  in  the  administering  of  the  school. 

In  five  of  the  ten  hospitals  considered  in  this  section,  the  same  person 
who  administers  the  training  school  is  expected  to  carry  all  or  at  least  the 
heaviest  part  of  the  teaching.  At  the  City  Hospital,  the  acting  superinten- 
dent of  the  training  school  teaches  7  subjects,  spending  19  hours  weekly  in 
class  work  in  addition  to  the  nursing  administration  of  a  hospital  with  nearly 
800  beds.  An  emergency  at  Fairview  makes  the  instructor  also  the  acting- 
superintendent  of  nurses,  though  even  in  normal  times  she  shares  many  of 
the  responsibilities  of  administering  the  school.  At  Glenville  and  Lake- 
wood,  the  administration  of  the  training  school  and  the  instruction  of  nurses 
is  carried  on  by  the  same  person.  At  St.  John's,  the  superintendent  of 
nurses  carries  in  addition  to  18  teaching  hours,  the  administrative  duties  of 
her  position  in  which  she  seems  to  have  no  assistance  even  for  the  clerical 
work. 

*  In  this  section  St.  Alexis  is  emitted  throughout,  owing  to  the  absence  of  systematized  instruction 
and  of  records  concerning  the  course  given  during  the  year  since  this  training  school  was  started. 


Nursing  729 

It  needs  no  argument  to  prove  that  such  duties  cannot  successfully  be 
combined.  The  more  pressing  demands  of  administration  take  precedence: 
the  teaching  must  inevitably  suffer.  If  a  higher  standard  of  instruction  is  to 
be  established,  the  appointment  of  full-time  instructors  is  an  urgent  neces- 
sity. The  only  alternative  is  a  central  school  of  nursing,  to  which  students 
may  be  sent  for  instruction. 

(a)  Chemistry 

Six  hospitals  give  instruction  in  this  subject,  City,  Fairview,  Glenville, 
Mt.  Sinai,  St.  John's  and  St.  Vincent's.  Four  others,  Huron  Road,  Lake- 
side, Lakewood  and  St.  Luke's,  avail  themselves  of  chemistry  courses  in  the 
nearest  high  schools.  Lakewood  pays  a  fee  of  $80.00  for  the  course;  the  in- 
struction for  the  students  of  the  other  hospitals  is  furnished  gratis  by  the 
city,  through  arrangement  with  the  Board  of  Education. 

Method 

Of  the  six  hospitals  in  which  chemistry  is  taught,  three  have  some  indi- 
vidual laboratory  work;  City,  where  half  the  time  allowed  is  given  to  the 
laboratory,  Mt.  Sinai,  and  St.  Vincent's,  where  only  a  few  hours  of  labora- 
tory instruction  are  provided.  In  the  others,  the  instruction  is  almost  wholly 
by  lecture  with  occasional  demonstration. 

Mt.  Sinai  gives  a  preliminary  course  to  students  who  have  not  had 
chemistry  in  high  school.     A  more  advanced  course  is  given  to  all  students. 

The  teaching  of  chemistry  in  the  high  schools  appears  to  be  of  high  grade 
though  limited  in  scope. 

Equipment 

Of  the  six  hospitals  which  provide  their  own  course  in  chemistry,  only 
one,  the  City  Hospital,  has  adequate  equipment  for  both  laboratory  work 
and  demonstration.  At  Mt.  Sinai  and  St.  Vincent's,  the  supplies  appear  to 
be  adequate  for  demonstration  purposes.  At  St.  John's,  Fairview  and 
Glenville,  the  equipment  is  inadequate  for  either  method  of  instruction. 

Hours 

The  hours  devoted  to  this  subject  in  Cleveland  training  schools  are  as 
follows : 

Lakewood  40  hours  (High  School  affiliation) 

Mt.  Sinai 33 

Lakeside 30  "      (High  School   affiliation) 

Huron  Road 30  "  "         .  "  " 

St.  Luke's     24  "  "  "  " 

City : 20  " 

St.  Vincent's 20  " 

St.  John's 18  " 

Glenville 12  " 

Fairview.  10  " 


730  Hospital  and  Health  Survey 

(6)     Anatomy  and  Physiology 
All  of  the  ten  hospitals  give  some  instruction  in  this  subject. 

Method  and  Equipment 

In  one  hospital,  Huron  Road,  instruction  is  almost  wholly  by  formal 
lectures  and  quizzes,  with  demonstrations  at  intervals;  in  the  others,  mainly 
by  recitations  on  assigned  texts  with  some  demonstrations.  In  only  two 
hospitals,  Lakeside  and  Mt.  Sinai,  is  there  in  addition  some  individual 
laboratory  work,  though  the  equipment  is  very  meagre. 

Hours 

The  hours  given  to  this  subject  in  Cleveland  training  schools  are  as  fol- 
lows : 

Lakeside .... ...70  hours 

Mt.  Sinai _ ...62 

St.  Vincent's..... _ ._ 60 

St.  Luke's... _ .56 

Huron  Road 51 

City , " 50 

St.  John's :. .....50 

Glenville _..._"_ .....40 

Lakewood:.. 36 

Fairview _-_ 30 

The  time  allotted  to  anatomy  and  physiology  in  4  schools  outside  of  Cleve- 
land is  as  follows: 

University  of  Cincinnati.. 150  hours 

University  of  Minnesota . '. 144      " 

Johns  Hopkins 110      " 

Children's  (Boston) .100       " 

(c)  Dietetics 

Of  the  ten  general  hospitals  eight  give  some  instruction  in  this  subject; 
i.  e.,  City,  Fairview,  Glenville,  Huron  Road,  Lakeside,  Lakewood,  Mt 
Sinai  and  St.  Luke's.  Two  other  hospitals,  St.  John's  and  St.  Vincent's, 
send  their  students  to  the  Y.  W.  C.  A.  for  instruction  in  this  subject.  With 
the  exception  of  Lakeside  and  St.  Luke's,  all  these  courses  strongly  empha- 
size cookery,  and  give  a  minimum  amount  of  instruction  in  the  basic  principles 
of  nutrition. 

This  failure  is  all  the  more  serious  owing  to  the  growing  recognition  of 
the  primary  importance  of  nutrition,  especially  in  relation  to  children  and 
the  movement  for  Child  Welfare  in  which  nurses  bear  increasing  responsi- 
bility. 

Equipment 

Lakeside  and  City  have  good  laboratories  fitted  for  teaching  dietetics 
although  at  the  City  it  is  not  adequately  supplied  with  individual  utensils 


Nursing  731 

At  Huron  Road  the  laboratory  is  fairly  adequate.  The  remaining  five  hos- 
pitals provide  decidedly  inferior  equipment  for  teaching  this  subject.  In 
some  instances  the  room  provided  is  unsuitable  (such  as  the  main  kitchen  at 
St.  Luke's),  and  in  others  there  is  a  lack  of  utensils  for  individual  work. 

Hours 

The  time  allotted  to  this  subject  in  Cleveland  training  schools  is  as  fol- 
lows : 

Mt.  Sinai -60  hours 

Lakeside.. -52  " 

St.  Vincent's .45  " 

St.  John's :... 45  " 

St.  Luke's , -. 44  " 

City ... __l _ 40  " 

Huron  Road 40  " 

Fairview. 32  " 

Lakewood 25  " 

Glenville..' 24  " 

In  four  schools  outside  of  Cleveland  the  hours  given  in  dietetics  and 
cookery  are  as  follows : 

University  of  Minnesota 70  hours 

Philadelphia  General 66      " 

Children's  (Boston) ...„ 56      " 

Boston  City 56      "       / 

(d)  Bacteriology 

x\ll  of  the  hospitals  give  some  instruction  in  bacteriology,  but  in  none  is 
there  adequate  equipment  for  the  individual  laboratory  work  essential  for 
this  subject. 

Equipment 

Material  for  demonstration  in  bacteriology  is  good  at  Mt.  Sinai,  and 
fairly  good  at  Lakeside  and  St.  Vincent's.  At  all  the  other  hospitals  this 
equipment  is  very  meagre. 

Hours 

The  time  devoted  to  this  course  in  Cleveland  training  schools  is  as  fol- 
lows: 

St.  Luke's 36  hours 

Huron  Road _. : , 24  " 

Mt.  Sinai 21  " 

City 20  " 

Lakeside .20  " 

St.  Vincent's ..: .20  " 

Fairview 12  " 

Glenville... J 12  " 

Lakewood 11  " 


732  Hospital  and  Health  Survey 

At  St.  John's,  this  course  is  combined  with  hygiene. 

In  four  schools  outside  of  Cleveland,  the  hours  given  in  bacteriology  are 
as  follows: 

University  of  Minnesota 99   hours 

Children's  (Boston) 76 

University  of  Cincinnati... ; ..75      " 

Presbyterian  (Chicago) 70      " 

Method 

In  only  one  of  these,  Mt.  Sinai,  is  individual  laboratory  work  given,  and 
even  there  with  inadequate  space  and  too  meagre  equipment  to  make  this 
form  of  instruction  effective.  The  course  is  divided  into  half  laboratory  and 
half  recitations  on  assigned  texts. 

Lakeside,  which  has  no  laboratory  work,  could  probably  arrange  for  it 
by  utilizing  more  extensively  the  possib'lities  of  the  pathological  department 
of  the  hospital.  Half  of  the  course  at  Lakeside  is  devoted  to  demonstration 
by  the  instructor  and  half  to  lecture  and  recitation. 

At  the  other  eight  hospitals,  the  method  of  instruction  varies,  being  mostly 
demonstration  at  St.  Luke's  and  St.  Vincent's,  and  mostly  lectures  at  Fair- 
view  and  Glenville.  The  others  combine  these  methods.  At  St.  John's  the 
work  in  bacteriology  is  not  given  as  a  separate  course,  but  in  combination 
with  the  course  in  hygiene. 

Instruction  in  Other  Subjects 

The  length  of  the  course  is  only  one  factor,  and  by  no  means  the  most 
important  factor,  in  determining  the  value  of  the  instruction.  Yet  the  pro- 
portion of  time  devoted  to  various  groups  of  subjects  is  highly  indicative. 

Comparisons  of  the  time  devoted  to  instruction  in  the  more  advanced 
subjects  are  difficult  to  make,  since  the  classification  and  arrangement  of 
subjects  show  wide  variation.  Thus,  in  one  school  the  lectures  on  gynecology 
are  included  in  the  course  in  surgical  diseases,  in  another  in  the  course  in 
obstetrics,  and  in  others,  as  a  separate  series.  In  the  same  way  the  lectures 
in  operating  room  technics  orthopedics,  and  eye,  ear,  nose  and  throat  dis- 
eases are  sometimes  given  as  separate  courses,  and  at  other  times  included  in 
the  general  surgical  lectures. 

In  the  same  way,  it  is  difficult  to  make  comparisons  of  instruction  in 
the  different  branches  of  medicine.  Thus,  communicable  diseases,  nervous 
and  mental  diseases,  occupational  diseases,  venereal  and  skin  diseases,  and 
pediatrics,  are  given  as  separate  courses  in  some  schools,  and  in  others  two 
or  more  are  combined  into  a  single  course.  In  one,  all  these  subjects  are  given 
as  one  course,  under  the  title  of  medical  diseases. 

Notwithstanding  these  differences  in  classification,  comparisons  can 
fairly  be  made  between  groups  of  allied  subjects.  Thus,  we  may  combine 
in  one  group  under  the  general  title  of  surgical  subjects  the  following:  eye, 


Nursing  733 

ear,  nose  and  throat  diseases,  gynecology,  operating  room  technic,  orthope- 
dics and  surgical  diseases.  The  number  of  hours  of  instruction  given  to  these 
surgical  subjects  in  9  Cleveland  training  schools,  ranges  from  34  to  73.  One 
school  cannot  be  included,  since  in  that  school  gynecology  is  included  in 
obstetrics. 

Again,  comparisons  may  fairly  be  made  by  grouping  under  the  single 
head  of  medical,  the  following  subjects:  communicable  diseases,  medical 
diseases,  nervous  and  mental  diseases,  pediatrics,  and  venereal  and  skin 
diseases.  In  this  group  of  medical  subjects,  Cleveland  schools  give  fronr|52 
to  109  hours  of  instruction. 

Hours  of  Instruction  in  Three  Groups  of  Subjects 

Preliminary        TOTAL 
Medical  Surgical  Sciences       All  Subjects 

City 90  43 

Fairview 61  34 

Glenville 56  48 

Huron  Road 82  65 

Lakeside 92  70 

Lakewood- 54  59 

Mt.  Sinai 52  * 

St  John's. 109  73 

St.  Luke's 62  44 

St.  Vincent's _ 88  60 

In  obstetrics  the  hours  given  range  from  12  at  St.  Luke's  to  31  at  Huron 
Road.  Except  for  Lakewood,  which  gives  18  hours,  the  time  devoted  to 
this  subject  in  the  other  hospitals  is  from  20  to  30  hours. 

The  total  number  of  subjects  listed  in  the  curricula  of  the  Cleveland 
training  schools  ranges  from  17  to  29,  in  addition  to  the  four  fundamental 
sciences  already  considered.  These  four  sciences,  viz.  anatomy  and  physi- 
ology, bacteriology,  chemistry,  and  dietetics  and  cookery,  may  be  considered 
the  preliminary  subjects,  or  those  introductory  to  the  specifically  technical 
and  professional  work  to  follow.  In  nursing  schools  already  affiliated  with 
colleges  and  universities,  the  tendency  is  to  consider  these  subjects  pre- 
requisite to  the  strictly  professional  training. 

It  is  significant  that  the  Cleveland  hospitals  devote  to  these  four  sub- 
jects from  20%  to  28%  of  the  total  time  devoted  to  class  instruction,  leaving 
only  from  72%  to  80%  to  the  subjects  that  constitute  the  main  body  of  pro- 
fessional instruction.  It  is  instructive  to  compare,  for  example,  the  time 
devoted  to  the  group  of  medical  subjects,  which  ranges  from  8%  to  19%  of 
the  total  time  allowed  for  class  room  instruction,  or  to  the  group  of  surgical 
subjects,  which  ranges  from  7%  to  13%,  with  the  time  devoted  to  the  pre- 
liminary group  which  ranges  from  20%  to  28%.  When  it  is  recalled  that 
the  time  allowed  for  the  preliminary  subjects,  though  large  in  proportion  to 

*  Figures  not  comparable,  since  gynecology  is  included  in  course  in  obstetrics. 
t  Includes  a  course  in  hygiene  which  is  combined  with  bacteriology. 


130 

472 

76 

365 

88 

365 

122 

596 

162 

672 

112 

469 

176 

655 

148  f 

598 

140 

572 

145 

505 

734 


Hospital  and  Health  Survey 


the  total  hours  of  instruction,  is  in  reality  meagre,  the  disproportionate 
time  allotted  to  purely  professional  subjects  is  a  still  more  serious  indication 
of  the  inadequacy  of  the  curriculum. 

This  fault,  common  to  nursing  schools  in  general  and  not  peculiar  to 
Cleveland  schools,  illustrates  the  emphasis  that  has  universally  been  placed 
on  the  manual  side  of  the  nurses'  training,  to  the  exclusion  of  sufficient  class 
room  instruction. 


Proportion  of  Total  Class  Hours  Devoted  to  Medical  and  Surgical 
Groups  Compared  with  Proportion  Devoted  to  Preliminary 

Sciences*. 

Medical 

City 19  % 

Fairview 16 

Glenville.-- .*......  1 5 

Huron  Road 13 

Lakeside 13 

Lakewood.. 1 1 

Mt.  Sinai 8 

St.  John's 18 

St.  Luke's 10 

St.  Vincent's... 17 


gical 

Preliminary  Sciences 

9% 

27% 

9 

20 

13 

24 

10 

20 

10 

24 

12 

23 

t 

26 

12 

24 

7 

24 

12 

28 

Method  of  Instruction 

~*  In  the  presentation  of  most  of  the  purely  professional  subjects  three  of 
the  hospitals,  Fairview,  Glenville  and  St.  Luke's,  rely  mainly  on  the  lecture 
method.  In  the  other  hospitals  there  are  recitation  periods  in  connection 
with  most  of  the.  lecture  courses.  At  two  hospitals,  Lakeside  and  St.  Vin- 
cent's, periods  are,  in  many  subjects,  set  aside  for  demonstration. 

*  The  courses  in  psychology  and  venereal  and  skin  diseases,  however,  are 
purely  lecture  courses  except  at  St.  Vincent's  where  recitations  and  demon- 
strations are  given.  Likewise,  the  course  in  mental  and  nervous  diseases  is 
taught  entirely  by  lecture  except  at  Lakeside,  Mt.  Sinai  and  St.  Vincent's. 

The  correlation  between  class  and  ward  instruction  in  Cleveland  training 
schools  seems  on  the  whole  to  be  as  carefully  planned  as  in  other  schools  of 
comparable  standing.  As  long  as  students  staff  the  wards  at  need,  com- 
plete correlation  of  theory  and  practice  is  probably  impossible.  Yet  in  many 
instances  in  Cleveland  there  was  evident  failure  to  come  as  near  as  possible 
to  the  best  practice.  Thus,  with  the  exception  of  St.  Vincent's,  the  classes 
in  surgical  diseases  and  medical  diseases  are  given  in  the  student's  second 
year  in  the  school,  after  she  has  presumably  for  many  months  had  the  care 
of  both  medical  and  surgical  patients. 

The  difficulty  encountered  by  small  schools  in  giving  proper  instruction 
to  their  students  is  illustrated  by  Lakewood  which  is  unable  to  give    all 

*  Other  subjects  not  specified  in  the  composition  of  these  groups  are  omitted  in  this  section. 
t   Figures  not  comparable  since  gynecology  is  included  in  course  in  obstetrics. 


Nursing  735 

courses  each  year,  since  the  number  of  students  in  each  class  is  small.  For 
example,  the  course  in  anatomy  and  physiology  is  given  in  alternate  years. 
Thus  instruction  in  this  fundamental  subject  is  not  given  to  some  students 
until  their  second  year.  In  the  same  class,  therefore,  are  students  iri  the 
second  year,  first  year,  and  preliminary  period.  These  last  are  the  only 
students  who  receive  this  instruction  at  the  time  when  it  should  properly 
be  given. 

The  advantages  that  would  result  from  combining  with  other  schools 
are  obvious. 

Iri  all  of  the  Cleveland  schools*  important  courses  are  given  in  the  even- 
ing, a  highly  undesirable  practice.  Evening  classes  not  only  deprive  students 
of  time  for  recreation,  but  also  require  mental  activity  when  students  are 
fatigued  from  the  day's  work  in  the  wards. 

St.  Vincent's  makes  extreme  demands  upon  its  students  in  this  respect. 
In  this  hospital  94  hours  of  class  instruction  are  given  after  six  o'clock  in  the 
evening.  In  this  evening  work  is  included  all  or  part  of  the  following  courses : 
bandaging,  massage,  medical  diseases,  surgical  diseases,  obstetrics,  eye,  ear, 
nose  and  throat  diseases,  venereal  diseases,  psychology  and  ethics.  Three 
other  hospitals,  Fairview,  Glenville  and  Lakeside,  give  50  hours  of  instruc- 
tion or  more  in  the  evening. 

CONDITIONS  OF  WORK 

Ratio  of  Nurses  to  Patients 

The  ratio  of  student  nurses  to  patients  which  is  desirable  for  teaching  as 
well  as  for  efficiency  of  service,  is  influenced  by  differing  conditions  in  different 
services  and  even  in  different  wards. 

The  best  general  opinion  places  the  desirable  ratio  in  an  active  ward 
service  at  about  1  nurse  to  5  patients  on  day  duty;  1  nurse  to  10  patients  on 
night  duty. 

In  Cleveland,  of  the  8  hospitals  for  which  information  is  available,  5 
hospitals  meet  this  desirable  ratio  for  day  duty.  These  hospitals  are:  HurOn 
Road,  Lakeside,  Mt.  Sinai,  St.  John's f  and  St.  Luke's.  Of  the  remaining 
three  hospitals,  Fairview  and  St.  Vincent's  fall  short,  having  a  ratio  of  1 
nurse  to  8  patients,  while  the  City  Hospital  provides  only  half  the  requisite 
number  of  student  nurses.  This  lack  is  in  part  supplemented  by  helpers  in 
some  wards. 

"^  For  night  duty,  only  1  hospital,  St.  John's,  comes  up  to  the  desired  figure. 
The  others  range  from  1  nurse  to  12  patients  at  Mt.  Sinai,  to  1  nurse  to  27 
patients  at  St.  Vincent's.  At  the  City  Hospital,  the  ratio  was  given  as  1  to 
25,  but  examination  of  the  hospital's  own  records  showed  on  the  night  of 
January  22nd  that  it  had  been  possible  to  provide  only  one  nurse  to  40 
patients. 

*  Information  on  this  point  was  not  obtained  from  Huron  Road. 

f  On  the  day  of  inspection  a  lower  ratio  was  found,  i.  e.  1:9.7  on  medical  floor;  1:8  in  women's  surgical 
ward. 


736  Hospital  and  Health  Survey 

The  ratio  of  students  to  patients  in  private  service  must  necessarily  be 
higher  because  this  is  a  room  service.  According  to  the  standard,  1  nurse 
to  3  patients  is  correct  for  day  duty;  1  nurse  to  5  patients  at  night.  In  almost 
all  the  hospitals  the  ratio  either  just  meets  or  falls  slightly  below  the  desired 
figure  for  day  duty.  Night  duty  shows  a  wider  deviation  from  the  standard, 
St.  Vincent's  providing  only  1  to  16  patients. 

HOURS  OF  DUTY 

1.  Day  Duty 

In  the  past,  the  failure  of  the  trainng  schools  as  educational  institutions 
has  been  due  largely  to  the  excessive  hours  of  labor  required.  To  state  the 
case  is  to  prove  it.  To  expect  study  or  intelligent  application  from  students 
is  manifestly  impossible  in  addition  to  the  "  nine-to-ten  -hour  working  day, 
the  twelve-hour  night  and  the  seven-day  week,"  which,  according  to  the 
standard  curriculum,  is  "still  required  in  most  hospitals."  During  the  past 
year  the  introduction  of  the  eight-hour  day  has  made  marked  advances. 

Eight  Hours 

In  Cleveland  three  of  the  thirteen  training  schools  have  nominally  an' 
eight-hour  day.  These  are  Huron  Road  (where  there  is,  however,  a  nine- 
hour  day  in  private  service),  Lakeside  and  Mt.  Sinai.  This  good  showing  is, 
however,  lessened  by  the  fact  that  in  all  three  hospitals  class  work  and  study 
and  meal  times  fall,  as  is  customary,  in  the  students'  so-called  "free  off-duty 
time."  At  Mt.  Sinai  class  work  exceeding  one  hour  per  day  is  counted  as 
time  on  duty,  at  Huron  Road  extra  time  is  allowed  off  "when  possible." 
At  all  three  hospitals  one  half -day  off  is  given  on  Sundays.  In  some  services 
there  are  additional  hours  off  on  Sunday.  All  three  hospitals  give  one 
half-day  off  weekly. 

Eight  and  One-half  to  Nine  Hours 

At  the  City  Hospital  the  hours  of  duty  range  from  83^  to  9,  and  are 
reduced  to  4^  on  Sunday.  Class  time  is  occasionally  counted  as  time  on 
duty.     A  half-day  weekly  is  allowed. 

Nine  Hours 

The  remaining  nine  hospitals  have  a  nine-hour  day  on  five  days  of  the 
week.  All  give  one-half  day  off  per  week  and  vary  in  their  hours  on  Sunday, 
St.  John's  and  St.  Vincent's  having  nine  hours*,  and  the  others  ranging 
downward  to  four  and  a  half. 

It  should  be  noted  that  at  Fairview  and  Lakewood,  class  time  is  cpunted 
as  time  on  duty,  and  at  Glenville  this  is  occasionally  done.  In  consequence, 
the  work  on  the  wards  at  these  3  hospitals  is  often  less  than  nine  hours,  par- 
ticularly in  the  junior  year.  At  St.  John's  juniors  have  only  8  hours  on 
the  wards. 

*  On  every  third  Sunday  hours  of  duty  reduced  to  2  and  1  1-2  hours  respectively,  at  these  two 
hospitals. 


Nursing  737 

2.  Night  Duty 

The  educational  value  of  night  duty  lies  in  part  in  the  added  responsi- 
bility and  initiative  which  it  entails  for  the  students.  Obviously,  however,  the 
benefit  of  this  service  is  obtained  at  the  cost  of  added  physical  and  nervous 
exertion.  The  assignment  to  night  duty  should,  therefore,  be  neither  too 
long  in  duration  nor  too  frequent;  and  careful  provision  should  be  made  to 
furnish  to  the  students  on  night  duty  quiet  and  privacy  for  sleep  in  the  day 
time.  These  primary  precautions  in  the  interest  of  health  and  education 
appear  often  to  be  ignored.  Moreover,  the  study  of  individual  students 
shows  frequent  examples  of  exceeding  the  period  of  time  planned  for  night 
service. 

Night  duty  should  be  assigned  with  special  reference  to  the  nursing  ex- 
perience to  be  obtained  which  may  obviously  be  great  in  medical  and  obstet- 
rical services,  but  is  negligible  in  a  surgical  service. 

Length  and  Frequency  of  Night  Duty 

Eight  Hours 

Lakeside,  Mt.  Sinai  and  Fairview  have  eight-hour  duty.  At  all  three 
hospitals  the  term  of  the  service  is  nominally  two  months.  Mt.  Sinai  suc- 
ceeds in  keeping  night  duty  substantially  within  the  limits  set  for  it,  but  at 
Lakeside  continuous  periods  of  night  duty  though  not  intended  to  exceed 
8  weeks,  have  in  fact,  according  to  the  hospital  records  for  the  present  senior 
class,  run  as  long  as  16  weeks.  No  data  on  this  point  were  obtained  from 
Fairview. 

Lakeside  and  Fairview  plan  three  periods  of  night  duty,  Mt.  Sinai  four, 
totalling  respectively  six  and  eight  months. 

Over  Eight  Hours  and  Less  than  Twelve 
Four  hospitals  fall  in  this  group. 

Cleveland  City  requires  nine  and  a  hah  hours  night  service,  with  one  hour 
off  for  a  night  lunch.     The  term  of  duty  here  is  only  two  weeks  at  a  time. 

Cleveland  Maternity  and  Glenville  have  10  hours,  Glenville  having  six 
terms  of  six  weeks  each,  totalling  nine  months. 

Huron  Road  has  11  hours  in  periods  of  one  and  two  months,  totalling 
five  months.     This  hospital  gives  one  night  off  duty  per  week. 

Twelve  Hours 

Five  hospitals  have  a  twelve-hour  night,  with  a  half  hour  off  for  a  night 
lunch.  These  hospitals  are  Lakewood,  St.  Alexis,  St.  John's,  St.  Luke's, 
St.  Vincent's.  Of  these,  two  have  a  half-night  off  at  regular  intervals,  Lake- 
wood  monthly,  and  St.  John's  fortnightly.  The  term  of  duty  ranges  from 
six  periods  of  eight  weeks  each  (or  nearly  a  year)  at  Lakewood,  to  three  or 
possibly  more  periods  of  one  month  each  at  St.  Alexis.* 

*  At  the  13th  hospital,  St.  Ann's,  affiliating  students  are  not  assigned  to  night  duty. 


738  Hospital  and  Health  Survey 


Classes  During  Night  Duty 

Lack  of  consideration  for  the  students'  health  and  study  is  apparent  in 
the  custom  of  holding  classes  in  the  early  morning  or  at  early  afternoon 
hours,  before  the  nurses  have  satisfied  the  primary  need  of  sleep. 

In  six  of  eleven  hospitals  in  Cleveland,  there  are  early  morning  classes  for 
students  on  night  duty.  These  six  hospitals  are:  City,  Glenville,  Huron 
Road,  Mt.  Sinai,  St.  Luke's,  and  St.  Vincent's.  One  hospital,  Fairview,  has 
classes  in  the  early  afternoon  at  two  o'clock.  The  four  remaining  hospitals, 
Lakeside,  Lakewood,  St.  Alexis  and  St.  John's,  have  classes  at  a  more  rea- 
sonable hour,  that  is,  after  three  o'clock. 

Time  Off  After  Night  Duty 

The  strain  of  night  duty  is  often  recognized  by  allowing  a  brief  vacation, 
after  each  term  of  service.  With  the  single  exception  of  Lakeside,  this  cus- 
tom is  followed  by  the  Cleveland  training  schools.  The  time  off  varies  from 
one  to  two  and  a  half  days.     At  St.  Vincent's  three  days  off  are  given. 

Sleeping  Quarters  for  Night  Nurses 

To  afford  quiet  and  privacy  for  rest  during  the  day  to  the  students  on  night 
duty,  special  rooms  or  dormitories  should  be  provided  for  them.  Four 
hospitals,  St.  John's,  St.  Vincent's,  City  and  Cleveland  Maternity,  have 
such  an  arrangement.  In  the  other  hospitals  little  effort  is  made  in  this 
direction.  As  most  rooms  are  double,  it  may  frequently  happen  that  a  day 
and  a  night  nurse  share  a  room.  An  attempt  is  made  to  put  room-mates 
on  night  duty  at  the  same  time,  but  this  is  difficult  and  often  impossible  to 
arrange. 

Vacation 

With  four  exceptions,  Cleveland  training  schools  give  a  3-weeks'  vacation 
each  year.  The  schools  which  allow  only  2  weeks  for  vacation  are  the  City, 
St.  Alexis,  St.  Vincent's  and  St.  Luke's. 

Provision  of  Ward  Helpers 

One  of  the  most  obvious  wastes  of  the  student's  time  and  energy  in  the 
present  organization  of  training  schools  is  the  excessive  amount  of  house- 
work required,  and  the  failure  to  supply  ward  helpers. 

The  hospitals  in  Cleveland  differ  greatly  in  this  respect.  In  most  of 
them  it  is  taken  for  granted  that  the  student  nurse  performs  a  large  part  of 
such  duties.  From  actual  observation  in  the  wards  it  appears  that  with 
the  exception  of  one  hospital,  from  two  to  eight  hours  daily  are  spent  by 
student  nurses  as  occasion  arises  in  non-educational  duties  such  as: 

Making  surgical  supplies. 

Running  sterilizer. 

Cleaning  and  mending  gloves. 


Nursing  739 

Dusting  and  cleaning  wards  and  service  rooms  and  rooms  of  private  patients. 

Folding  and  putting  away  linen. 

Setting  and  carrying  trays,  washing  dishes. 

Washing  soiled  linen,  tending  switchboard  and  front  door. 

At  Lakeside  3  probationers  and  3  advanced  students  are  regularly 
assigned  to  the  gauze  room  where  three-quarters  of  the  time  is  spent  in  the 
routine  preparation  of  surgical  supplies.  It  is  planned  that  each  student 
shall  spend  a  month  and  a  half  in  this  service  which  can  scarcely  have  any 
educational  value  after  the  first  two  weeks,  and  comes  appropriately  in  the 
probationary  period. 

The  only  considerable  attempts  to  relieve  the  nurse  by  providing  ward 
helpers  are  at  Huron  Road  and,  to  a  greater  extent,  at  Mt.  Sinai,  where 
the  students  devote  more  time  to  strictly  nursing  duties  than  in  other 
Cleveland  hospitals.  At  Mt.  Sinai  the  installation  of  thoroughly  modern 
equipment  has  simplified  the  problems  of  housekeeping  in  general.  The 
labor  involved  in  caring  for  patients  is  reduced  to  a  minimum  by  the  liberal 
provision  of  portable  equipment  and  by  the  introduction  of  labor-saving 
devices. 

Moreover,  the  students'  time  is  saved  at  this  hospital,  by  employing  at- 
tendants to  perform  a  multitude  of  routine  duties,  which  have  been  learned 
by  students  during  the  preliminary  period  and  are  educationally  valueless 
to  them  at  a  later  stage. 

The  failure  of  other  hospitals  to  supply  such  service  makes  the  example 
of  Mt.  Sinai  and  Huron  Road  all  the  more  noteworthy.  It  is  worth  while 
to  describe  the  arrangement  for  ward  helpers  at  Mt.  Sinai  in  some  detail.  On 
private  floors  attendants  are  employed  to  do  all  dusting,  caring  for  flowers, 
answering  the  telephones.  Half  an  hour  before  meals,  they  set  trays  in  the 
diet  kitchen,  the  nurse  serving  only  the  hot  food.  The  attendant  carries 
trays  to  and  from  the  patients'  rooms.  In  the  afternoon  she  is  employed 
in  making  surgical  supplies.  The  attendant  works  8  hours  per  day,  and  re- 
ceives $40.00  per  month  and  one  meal  a  day.  In  the  public  wards  lay  helpers 
are  employed  only  during  vacation  period. 

In  the  surgical  supply  room  two  full-time  women  are  employed  at  $50.00 
per  month  with  three  meals  a  day,  and  two  part-time  women  three  hours 
each  day.  These  women  were  employed  as  diet  kitchen  maids  at  $25.00  per 
month,  and  asked  to  be  employed  in  the  surgical  room  at  their  hours  off  in 
the  afternoon.  In  the  operating  room  one  full-time  woman  is  employed  at 
$50.00  per  month  and  three  meals  a  day.  She  cleans  instruments  and  the 
room,  and  makes  surgical  supplies. 

In  the  obstetrical  department  ward  helpers  do  the  same  general  duty  as 
on  the  other  wards.  In  addition,  the  attendant  has  charge*  of  all  clean 
linen,  sweeps  and  dusts  the  nursery,  and  holds  the  babies  during  supplement- 
ary feeding.  Thus,  the  housekeeping  duties  of  the  students  are  reduced  to 
a  minimum,  such  as  scrubbing  babies'  individual  basins,  and  sterilizing 
them.  While  students  are  supposed  to  make  surgical  supplies  in  spare  time, 
it  was  noted  that  in  fact,  their  time  was  fully  occupied  with  strictly  nursing 
duties. 


740  Hospital  and  Health  Survey 

Undoubtedly  the  elimination  of  routine  housekeeping  duties  and  other 
non-educational  tasks  has  done  much  to  foster  the  study  by  student  nurses  of 
cases  on  the  wards,  and  their  unusual  intelligence  in  discussing  these  cases. 

But  even  at  Mt.  Sinai  it  is  estimated  that  the  student  may  spend  daily 
one  and  a  half  hours  folding  and  putting  away  linen  and  about  an  hour 
cleaning  wards  and  service  rooms,  and  the  unique  opportunities  of  the  dis- 
pensary as  ja  training  field  are  only  partly  utilized  because  students'  time 
there  is  more  than  half  filled  with  routine  cleaning  and  arranging  supplies. 

LIVING  CONDITIONS 

The  Nurses'  Residence* 

To  counterbalance  the  strain  of  abnormal  conditions  met  in  the  hospital 
wards,  the  student  nurse  needs  the  relief  of  outside  interests  and  a  wholesome 
home  life.  These  needs  are  too  often  left  unprovided  for  when  the  nurses 
are  lodged  in  ordinary  houses  improvised  as  homes  for  a  large  student  body 
without  proper  bedrooms  or  lavatory  equipment,  and  without  any  special 
rooms  for  study  or  recreation. 

If  the  nurses  live  in  the  hospital  building,  they  do  not  have  sufficient 
opportunity  to  shake  off  the  ward  atmosphere.  Even  mild  social  recreations 
are  often  made  impossible  by  the  close  proximity  of  the  patients.  The 
nurses'  residence  should,  therefore,  be  a  separate  building  in  the  near  vicinity 
of  the  hospital.  It  should  be  constructed  to  meet  the  needs  of  a  nurses' 
home,  with  reception  and  recreation  room,  library,  class  room,  study  room 
and  single  bed  rooms,  with  proper  lavatory  equipment  and  such  accessory 
rooms  as  kitchenette,  laundry  and  sewing  room,  exclusively  for  the  use  of 
the  students. 

In  Cleveland  all  of  the  hospitals  but  two,  house  their  nurses  in  separate 
buildings.  These  two  are  Lakeside  and  Huron  Road,  which  set  aside  a 
separate  wing  with  the  entrance  through  the  hospital.  At  St.  Vincent's 
and  St.  John's,  although  there  is  a  separate  building,  it  is  reached  only 
through  the  hospital,  and  is  undesirably  located  in  the  rear. 

The  nurses'  residence  at  the  City  Hospital  is  the  only  nurses'  residence  in 
Cleveland  which  is  satisfactory.  The  other  nurses'  homes  were  originally 
built  for  other  purposes.  Four  of  these,  Huron  Road,  Mt.  Sinai,  St.  Alexis, 
and  St.  Vincent's,  provide  no  nurses'  reception  room.  Four,  Glenville,  Lake- 
wood,  St.  Alexis  and  St.  John's,  provide  no  separate  recreation  room.  None 
have  a  room  set  aside  for  study. 

The  general  and  reference  libraries  are  inadequate  at  City,  Lakewood, 
St.  Alexis  and  St.  John's,  either  on  account  of  lack  of  books  and  magazines, 
or  owing  to  their  inaccessibility. 

Two  Cleveland  hospitals,  Lakeside  and  St.  Luke's,  have  a  social  director 
for  the  students. 

In  the  nurses'  homes  in  Cleveland,  the  double  room  is  the  rule,  the  single 
room  the  exception.     Even  more  undesirable  than  the  double  room  is  the 

*  Cleveland  Maternity  and  St.  Ann's  omitted  in  this  section. 


Nursing  741 

dormitory.  Six  of  the  eleven  nurses'  homes  visited,  lodge  some  of  their 
students  in  dormitories.  At  St.  Vincent's  sixty-five,  of  a  possible  eighty- 
nine  students,  are  housed  in  dormitories  having  from  three  to  ten  beds  each. 

Obviously,  the  nurses'  residence  should  have  adequate  hygienic  surround- 
ings for  the  nurse  and  provision  for  personal  hygiene  and  immaculate  clean- 
liness. Ample  lavatory  facilities  are  a  necessity,  the  provision  of  one  bath- 
room to  six  students  being  regarded  as  the  minimum  requirement.  The 
nurses'  residence  at  the  City  Hospital  is  excellent  in  this  respect,  and,  in 
addition,  stationary  basins  are  provided  in  each  room.  There  is  also  a  large 
lavatory  adjacent  to  the  dining  room,  though  by  a  curious  omission  there 
are  no  toilets  in  this  lavatory. 

The  other  institutions  make  fairly  adequate  provisions  with  respect  to 
general  lavatories,  excepting  St.  Luke's  and  one  floor  at  St.  John's. 

Dietary 

Since  student  nurses  are  engaged  in  arduous  physical  and  mental  work, 
careful  selection  of  their  food  is  a  matter  of  prime  importance.  This  appears 
to  receive  reasonable  consideration  in  the  Cleveland  hospitals. 

The  nutritional  value  of  attractive  service  should  not  be  overlooked.  A 
cafeteria  service,  three  meals  a  day  for  three  years,  is  not  satisfactory,  es- 
pecially in  the  case  of  persons  who  must  be  on  their  feet  long  hours  every 
day.  In  Cleveland  three  of  the  hospitals,  Lakeside,  Lakewood  and  Mt. 
Sinai,  rely  on  cafeteria  service,  good  of  its  kind.  Under  existing  labor  con- 
ditions, it  is  justifiable,  but  it  should  clearly  not  be  a  permanent  feature  of 
the  nurses'  dining  room. 


RECOMMEND  A  TIONS 

1.     A  UNIVERSITY  SCHOOL  OF  NURSING 

It  is  strongly  urged  that  a  University  School  of  Nursing  be  established  at  the  earliest 
possible  date.  This  school  should  be  on  the  same  academic  basis  as  are  other  under- 
graduate schools  of  the  University.  The  instructors  should  be  members  of  the  University 
staff.  All  students  should  fully  meet  the  usual  requirements  for  admission,  and  the  com- 
bined university  and  hospital  course  should  lead  to  the  Bachelor  of  Science  degree.  The 
didactic  instruction,  both  in  class-room  and  laboratory,  should  be  given  by  the  school. 

In  order  to  obtain  the  necessary  ward  practice,  the  training  school  should  make  con- 
tracts with  the  several  hospitals  whereby  the  latter  should  agree  to  receive  students  for 
training  in  specified  branches  of  nursing.  Affiliating  hospitals  should  be  required  to  meet 
the  standards  of  instruction  and  conditions  of  work  established  by  the  University,  in  order 
that  the  training  shall  be  of  grade  equal  to  that  furnished  in  practice  fields  of  other  schools 
of  the  University. 

Time  must  necessarily  elapse  before  a  University  School  of  Nursing  can  be  success- 
fully planned  and  launched.  In  the  interval  the  Cleveland  Training  Schools  should  take 
immediate  steps  to  improve  the  present  course  of  training. 


742  Hospital  and  Health  Survey 


The  recommendations  which  follow  embody  some  of  the  obvious  changes  needed  to 
improve  working  and  living  conditions  for  the  student  nurses  and  to  strengthen  the  in- 
struction now  given. 

The  recommendations  as  to  the  content  of  the  curriculum  and  the  relative  length  of 
courses  are  not  here  given.  On  these  points  it  has  not  yet  been  possible  to  formulate 
conclusions,  as  noted  earlier  in  this  report  (see  page  712).  Studies  of  hospital  training 
schools  in  other  cities,  of  which  the  Cleveland  Survey  has  been  one,  are  now  in  progress, 
by  the  Committee  on  Nursing  Education.  From  detailed  observation  of  the  ward  experi- 
ence and  instruction  of  students  in  different  types  of  hospitals,  material  is  being  gathered 
on  which  the  Committee  will  base  its  ultimate  recommendations  for  a  detailed  curriculum. 

The  recommendations  which  follow  will,  it  is  believed,  not  only  improve  the  train- 
ing but  will  help  to  attract  students  of  higher  calibre,  who  have  been  repelled  by  the  un- 
necessary physical  hardships  and  inferior  instruction  of  the  present  training  schools. 

2.     ORGANIZATION  OF  THE  TRAINING  SCHOOL 

Various  proposals  as  to  the  organization  of  training  schools  are  presented  in  detail 
on  page  713  of  this  chapter  and  need  not  be  repeated  here. 

Cost  Accounting 

A  separate  and  detailed  budget  for  the  training  school  should  be  prepared,  and  a 
system  of  cost  accounting  should  be  adopted  to  show  the  total  cost  of  the  training 
school,  including  instruction,  maintenance,  etc.,  and  covering  the  value  of  services 
rendered  by  the  students  and  staff  of  the  school. 

Money  Allowance  to  Students 

Cleveland  training  schools  should  abandon  the  practice  of  paying  students,  and  should 
use  funds  thus  released  to  build  up  their  educational  work. 

Payment  to  Lecturers 

The  growing  practice  of  paying  the  members  of  the  medical  staff  who  teach  in  the 
school  of  nursing  should  be  generally  adopted. 

3.     MINIMUM  ENTRANCE  REQUIREMENT 

The  minimum  educational  requirement  for  admission  to  a  school  of  nursing  should 
be  not  less  than  completion  of  high  school. 

4.     SERVICES  OFFERED 

Hospitals  which  cannot  offer  adequate  clinical  facilities  for  instruction  in  the  four 
main  branches  (medical,  surgical,  children's  diseases  and  obstetrics),  as  well  as  in  the  im- 
portant special  branches  of  communicable  diseases  and  mental  and  nervous  disorders, 
should  provide  such  opportunities  for  their  students  by  affiliation  with  institutions  capable 
of  offering  them. 

It  is  urged  that  all  students  who  expect  to  enter  public  health  work  should  be  allowed 
to  elect  the  eight  months'  course,  but  at  the  least  they  should  be  allowed  the  four  months' 
period  of  training  in  the  University  District. 


Nursing 


743 


Dispensaries  and  social  service  departments  should  be  utilized  for  training  students 
as  soon  as  adequate  teaching  and  supervision  are  assured. 


5.     INSTRUCTION 

Instruction  in  the  fundamental  sciences  and  in  the  other  necessary  branches  can  best 
be  afforded  by  a  central  training  school,  under  University  auspices,  such  as  is  recom- 
mended above. 

If  such  University  affiliation  should  not  prove  feasible,  or  if  there  is  delay  in  joining 
it,  it  is  recommended  that  several  training  schools  of  similar  grade  in  Cleveland  combine 
in  furnishing  theoretical  instruction  to  their  students.  No  lower  educational  requirement 
for  admission  should  be  accepted  than  that  required  for  University  entrance. 

Teaching  of  Nursing  Procedures 

Whatever  combination  with  other  schools  may  be  made  in  the  future,  whether  under 
University  or  other  control,  it  is  clear  that  a  demonstration  room  and  equipment  for  teach- 
ing nursing  procedures  will  continue  to  be  needed  in  every  hospital  that  admits  students 
for  training.  It  is  therefore  urged  that  every  school  not  now  so  supplied  for  demonstra- 
tion and  individual  practice,  should  provide  these  needed  facilities  without  delay. 

The  technical  work  of  probationers  and  also  of  more  advanced  students  should  be 
supervised  by  the  instructor.  Every  student  should  be  carefully  taught  each  nursing 
procedure  in  the  class  room  before  she  is  allowed  to  carry  it  out  on  the  wards.  Moreover 
each  student  should  be  supervised  by  the  instructor  when  she  carries  out  any  procedure 
for  the  first  time,  and  she  should  not  be  assigned  to  any  duty  regularly  until  the  instructor 
has  made  sure  that  she  is  proficient,  and  has  notified  the  head  nurse  to  that  effect.  Pro- 
cedures should  be  demonstrated  to  head  nurses  by  the  instructor. 

Similarly,  the  teaching  of  diet  in  disease  must  always  be  given  at  least  in  part  within 
the  hospital  in  order  to  correlate  class  instruction  with  the  actual  feeding  of  patients  on 
the  wards.  It  is  therefore  urged  that  every  hospital  not  now  possessing  adequate  class- 
room and  laboratory  facilities  for  the  teaching  of  diet  in  disease  should  provide  these 
facilities  immediately.     Equipment  similar  to  that  needed  for  teaching  dietetics  is  needed. 

Teaching  of  Fundamental  and  Technical  Subjects 

Prior  to  the  establishment  of  a  central  school  of  nursing  various  immediate  improve- 
ments in  teaching  and  equipment  should  be  made  in  the  fundamental  sciences  and  the 
technical  subjects.  These  improvements  have  been  indicated  in  separate  reports  to  the 
different  hospitals. 


6.     CONDITIONS  OF  WORK 

Neither  day  nor  night  duty  should  exceed  eight  hours  out  of  the  twenty-four.  Class 
hours  should  be  included  in  this  time.  Students  on  night  duty  should  in  no  case  have 
classes  until  after  a  period  of  at  least  eight  hours  has  been  allowed  for  sleep.  Night  work 
should  be  limited  to  short  terms  of  not  more  than  one  month  each.  To  compensate  for 
the  strain  of  night  work  a  brief  vacation  should  be  given  at  the  completion  of  each  term. 


744  Hospital  and  Health  Survey 


7.     LIVING  CONDITIONS 

The  provision  of  suitable  living  conditions  and  opportunities  for  recreation  are  urged 
as  matters  of  first  importance. 

The  nurses'  residence  should  be  separate  from  the  hospital,  but  in  close  proximity  to 
it.  It  should  contain  reception  and  recreation  rooms,  library,  class  and  study  rooms, 
and  accessory  rooms  for  the  exclusive  use  of  the  students,  such  as  kitchenette,  laundry 
and  sewing  rooms.  Students  should  have  single  bedrooms,  and  there  should  be  generous 
provision  of  bathrooms  and  lavatories. 

For  students  on  night  duty  special  sleeping  rooms  should  be  provided,  which  should 
be  situated  so  that  quiet  and  freedom  from  disturbance  are  assured. 

Special  attention  should  be  given  to  providing  recreation,  both  indoors  and  out. 
Facilities  for  indoor  recreation  might  well  include  a  gymnasium  and  swimming  pool,  and 
should,  at  the  least,  include  good  facilities  for  dancing.  If  space  permits,  tennis  courts 
should  be  provided  for  the  exclusive  use  of  the  nurses. 

It  is  recommended  that  social  directors  should  be  appointed,  who  should  be  charged 
with  directing  the  recreation  and  social  life  of  the  students. 

8.     REDUCTION  OF  PRESENT  THREE-YEAR  COURSE 

With  the  practical  development  of  the  recommendations  given  above  it  should  prove 
possible  to  reduce  the  present  three-year  course  for  all  nurses.  At  this  time,  for  the  reason 
given  above  (see  page  712),  it  is  not  possible  to  make  specific  recommendations  as  to  the 
amount  of  time  by  which  the  regular  nurses'  training  may  safely  be  reduced.  The  higher 
standard  of  admission,  the  elimination  of  uneducational  house  work,  better  instruction, 
practical  and  theoretical,  a  better  balanced  provision  of  services,  will  enable  the  course  to 
be  reduced  by  at  least  eight  months.  « 

The  principles  underlying  such  reduction  of  the  present  three-year  course  are  two: 

1.  That  all  nurses-in-training  should  have  the  same  basic  education, 
after  which  they  may  be  graduated  with  the  certificate  or  diploma  of  nurse; 

2.  That  in  addition,  courses  should  be  provided  leading  to  special 
diploma  for  public  health  nurses,  for  teaching  and  administrative  positions  in 
hospitals,  and  for  specialties  in  private  duty. 

This  plan  is  proposed  in  the  belief  that  nurses  graduating  from  the  shorter  basic 
training  will  be  available  primarily  for  bedside  care.  The  more  advanced  courses  will 
attract  students  of  higher  calibre  who  are  needed  for  the  nursing  specialties,  especially  for 
teaching  and  administration  in  hospitals  and  for  public  health  work.  It  is  the  conviction 
of  the  Nursing  Survey  that  without  a  thorough  clinical  training  the  responsible  duties  in 
these  rapidly  developing  fields  cannot  be  successfully  met. 

9.     TRAINING  OF  COLORED  STUDENTS 

The  question  has  recently  been  raised  as  to  providing  opportunities  for  colored  stu- 
dents to  obtain  the  nurses'  training  in  Cleveland.  At  one  hospital — the  City  Hospital — 
this  is  a  question  of  practical  moment.  There  can  be  no  doubt  that  at  the  City  Hospital, 
where  the  training  school  is  maintained  by  the  city,  all  citizens  have  equal  rights.     The 


Nursing  ^> 

education  afforded  by  the  city  should  therefore  be  available  for  all  students,  irrespective 
of  color.  So  far  as  concerns  living  arrangements  at  the  hospital,  the  possibility  of  friction 
may  readily  be  removed  by  following  the  custom  of  allowing  colored  students  to  live  at 
home  during  their  training. 

Post  Graduate  Courses 

WESTERN   RESERVE   UNIVERSITY  COURSE 
IN  PUBLIC  HEALTH  NURSING 

Origin 

THE  impulse  that  led  to  the  founding  and  development  of  this  course 
came  from  a  group  of  lay  women  interested  in  the  Visiting  Nurse  Associa- 
tion. To  them  it  became  apparent,  as  visiting  nursing  broadened  from 
primarily  remedial  work  into  constructive  efforts  for  family  health,  that 
the  preparation  afforded  to  nurses  by  hospital  training  schools  was 
insufficient  to  prepare  them  for  the  social  and  preventive  work  required  m 
this  rapidly  developing  branch  of  nursing.  Additional  instruction  both,  in 
the  classroom  and  in  the  field  was  clearly  needed. 

With  the  same  vision  and  energy  from  which  Cleveland  has  richly  profited 
in  other  forms  of  nursing  and  health  work,  plans  for  a  course  of  training 
were  made  and  put  into  effect.  For  5  years  the  course  thus  established  was 
offered  by  the  Visiting  Nurse  Association,  with  the  assistance  of  the  De- 
partment of  Sociology  of  Western  Reserve  University,  the  Associated 
Charities,  the  Anti-Tuberculosis  League,  the  Babies'  Dispensary  and  Hos- 
pital, and  the  Department  of  Medical  Inspection  of  the  Board  of  Education. 
The  Visiting  Nurse  Association  took  the  financial  and  administrative  re- 
sponsibility, secured  a  director,  and  set  aside  as  a  practice  field  the  area  now 
covered  by  the  University  Public  Health  Nursing  District. 

As  the  work  of  training  developed,  it  became  clear  that  direction  might 
more  appropriately  be  exercised  by  an  educational  institution  than  by  an 
executive  organization.  After  5  years,  therefore,  the  Visiting  Nurse  Asso- 
ciation transferred  the  management  of  the  course  to  the  University,  and  in 
1916  it  became  a  constituent  part  of  the  Division  of  Health  Administration 
in  the  School  of  Applied  Social  Sciences. 

Organization 

The  organization  effected  was  excellent.  By  becoming  an  integral  part 
of  the  University,  the  stability  and  educational  purpose  and  standards  of 
the  course  were  assured.  At  the  same  time,  through  the  appointment  of  an 
advisory  committee  and  the  establishment  of  the  University  Public  Health 
Nursing  District,  the  course  has  maintained  its  close  connection  with  public 
health  nursing  activities,  and  has  secured  a  unique  field  for  the  instruction 
of  students  in  practical  work. 

The  Advisory  Committee  is  composed  of  13  members,  of  whom  a  lay 
woman  is  chairman.  The  superintendents  of  nurses  of  the  following  organi- 
zation are  members:  the  Division  of  Health,  the  Board  of  Education,  the 


746  Hospital  and  Health  Survey 

Visiting  Nurse  Association,  and  the  Babies'  Hospital  and  Dispensary.  The 
Dean  of  the  School  of  Applied  Social  Sciences  is  also  a  member,  and  the 
others  are  lay  women  respresentative  of  the  group  to  whom  Cleveland  owes 
much  of  its  progress  in  various  branches  of  health  work.  The  Director  of 
the  course  is  secretary  of  the  Committee.  So  long  as  such  a  group  forms  its 
policies  and  directs  its  activities,  the  maintenance  of  proper  balance  between 
theoretical  and  practical  work  seems  assured. 

The  University  Public  Health  Nursing  District  is  perhaps  the  most 
potent  single  factor  in  rendering  the  course  one  of  the  best  in  the  country. 
This  crowded  district  was  selected  as  a  practice  field  on  account  of  the  varied 
experience  it  affords  for  public  health  nursing.  The  course  is  planned  on 
the  principle  that  the  students  for  effective  training  must  not  only  observe 
the  work  of  others,  but  must  themselves  carry  responsibility,  under  expert 
supervision,  for  actual  practical  work.  The  plan  presupposes  that  field 
work  corresponds  to  laboratory  work  in  other  departments  of  the  University, 
and  that  it  should,  therefore,  be  controlled  by  the  School  in  order  that  it 
may  be  carried  on  according  to  sound  educational  methods. 

With  the  exception  of  school  nursing,  the  work  in  the  University  District 
is  almost  entirely  generalized.  This  arrangement  is  of  great  value  to  the 
student,  since  it  eliminates  the  waste  of  time  inevitably  resulting  from 
assignments  of  work  distributed  among  several  different  agencies.  But 
still  more  important,  it  teaches  the  student  methods  of  dealing  with  every 
type  of  health  problem  encountered  in  the  families  she  visits,  and  thus 
forms  an  excellent  preparation  for  community  work.  In  post-partum  work, 
however,  the  opportunities  are  meagre,  since  much  of  this  service  at  the 
present  time  is  carried  by  the  nurses  of  the  Cleveland  Maternity  Hospital. 

The  organization  of  the  University  District,  and  the  character  of  the  field 
work  are  described  in  a  special  report. 

Finances 

.  The   budget   is   prepared   by   the   Advisory    Committee.     Expenditures 
must  be  approved  by  the  Committee. 

The  expenses  of  the  course,  above  receipts  from  tuition  fees,  are  met  by 
the  University  and  contributions  from  the  Visiting  Nurse  Association  and 
the  Anti-Tuberculosis  League.  The  Board  of  Health  gives  the  supplies  used 
for  its  own  especial  activities  in  the  district,  but  is  not  empowered  to  appro- 
priate funds  for  the  work  of  a  private  organization. 

Staff 

The  teaching  staff  consists  of  the  director,  5  nurse  instructors  in  the 
University  District,  the  instructors  in  the  several  courses  given  by  the  School 
of  Applied  Social  Sciences  and  a  number  of  lecturers. 

The  director  of  the  course  holds  the  appointment  of  Assistant  Professor 
in  the  University,  and  teaches  one  course.  She  is  directly  responsible  to  the 
Dean  of  the  School  and  to  the  chairman  of  the  Advisory  Committee.  In 
addition  to  administering  the  work  of  the  course,  she  is  responsible  for  de- 


Nursing  747 

tailed  supervision  of  the  work  of  the  University  District.  She  also  lectures 
in  training  schools,  serves  on  the  Central  Committee  on  Public  Health 
Nursing,  and  in  her  official  as  well  as  personal  capacity  she  is  called  upon  to 
advise  and  assist  in  many  nursing  activities  in  the  community.  It  is  clear 
that  the  responsibilities  of-  her  office  are  many  and  heavy. 

The  work  of  students  in  the  University  District  is  directly  supervised  by 
the  five  instructors.  These  nurses,  all  of  whom  are  graduates  of  the  course, 
have  been  selected  for  their  ability  to  teach  and  to  supervise.  That  their 
work  is  of  a  high  order  is  shown  in  the  report  on  the  University  District. 
One  of  the  instructors  acts  as  assistant  director  in  addition  to  her  other 
duties.  Her  responsibility  for  administration  is  however  limited  except  dur- 
ing the  absence  of  the  director. 


Students 

For  admission  to  the  course,  applicants  must  be  graduates  of  approved 
training  schools  for  nurses,  and  must  be  eligible  for  membership  in  the  Na- 
tional Organization  for  Public  Health  Nursing.  They  must  also  be  graduates 
of  high  schools,  or  have  received  an  equivalent  preliminary  education.  To 
the  latter  requirement,  however,  a  number  of  exceptions  have  been  made. 

Application  for  admission  to  the  course  is  made  on  the  regular  blank  of 
the  School  of  Applied  Social  Sciences.  Since  this  blank  calls  for  no  details 
of  the  nurse's  training,  it  is  not  especially  well  adapted  for  this  group  of 
applicants.  Letters  are  sent  to  the  high  school  and  nurse's  training  school 
attended  by  the  applicant  requesting  a  general  statement  in  regard  to  her 
work  and  her  personal  qualifications.  Three  personal  references  are  also 
required,  and  to  each  of  the  persons  whose  names  are  given,  a  letter  of  inquiry 
is  sent. 

Credentials  of  applicants  are  evaluated  by  the  Advisory  Committee  in 
conference  with  the  Director  of  the  Course  and  the  Dean  of  the  School.  The 
final  decision  in  regard  to  admission  is  made  by  the  Dean. 

Students  who  complete  the  course  satisfactorily  receive  certificates. 

Students  not  registered  for  the  entire  course  are  admitted  for  four  months 
of  training  in  field  work.  No  certificates  are  granted  for  this  work,  but  those 
who  complete  the  work  satisfactorily  receive  15  points  of  University  credit. 
These  students  must  have  the  same  professional  and  educational  qualifica- 
tions as  those  taking  the  full  course. 

Pupil  nurses  from  any  training  school  meeting  the  standards  set  by  the 
Ohio  State  Association  of  Graduate  Nurses  may  be  received  for  two  months' 
experience  in  the  University  District.  These  pupils  must  have  completed  two 
years  of  training,  and  must  have  had  their  training  in  surgery,  and  in  ob- 
stetrics, if  possible. 


748  Hospital  and  Health  Survey 

During  the  year  ending  June  1,  1920,  the  following  number  of  students 
was  enrolled: 

One- Year  Course,  Graduate  Nurses.. 19 

Four  Months'  Field  Work: 

Graduate  Nurses 31 

Pupil  Nurses 11 

Total 61 

Sixty-four  pupil  nurses  were  received  for  two  months'  training.  These 
pupils  were  admitted  monthly,  the  number  varying  from  5  a  month  during  the 
summer  months  to  10  a  month  during  the  winter. 

The  total  number  of  nurses,  not  including  those  who  graduated  in  1920, 
who  have  received  certificates,  is  45. 

Instruction 

One  regular  course  is  offered,  which  leads  to  a  certificate.  It  extends 
over  one  academic  year,  and  is  divided  into  two  parts,  one  devoted  largely^to 
didactic  work,  the  other  to  field  work. 

The  didactic  work  is  given  during  the  first  semester,  and  consists /)f  jthe 
following  courses: 

Public  Health  Nursing..... 30  hours 

Hygiene  and  Preventive  Medicine. .24      " 

Bacteriology - 96 

Household  Problems 29 

Practical  Sociology 60 

Problems  in  American  Society.. -30 

Case  Work  with  Families.... 72 

Mental  Hygiene... —.10      " 

During  the  first  semester  the  students  spend  two  afternoons  (6  hours) 
weekly  in  work  with  the  Associated  Charities. 

Additional  courses  may  be  taken  by  students  exempted  on  the  basis  of 
previous  work  from  one  or  more  of  these  courses.  During  the  year  3  students 
so  exempted  took  courses  in  psychology,  government  and  social  legislation. 

The  character  of  the  didactic  work  of  the  course  could  not  be  judged, 
since  the  investigation  was  carried  on  in  the  second  semester,  after  the  lec- 
tures had  been  concluded.  It  was,  therefore,  impossible  to  evaluate  the 
class  room  teaching.  The  subjects  selected,  however,  are  those  specially 
needed  by  nurses  preparing  for  public  health  work. 

Field  Work 

One  semester,  or  approximately  4  months,  is  spent  in  field  work.  Ordi- 
narily, this  work  follows  directly  after  the  semester  devoted  to  theoretical 
work.     The  field  work  is,  however,  given  three  times  during  the  year.    In 


Nursing  749 

some  cases  the  students  take  field  work  in  the  summer  months,  and  begin 
the  theoretical  work  subsequently. 

The  usual  division  of  field  work  is  the  following : 

University  District 11  weeks 

School  Nursing 3  weeks 

Hospital  Social  Service  or  Humane  Society,  or  other 

Special  Agency  (observation) — 1  week 

Industrial  Nursing  (observation) 1  or  2  weeks  as  elected 

Rural  Nursing  (observation) 1  or  2  weeks  as  elected 

During  the  first  week  a  number  of  excursions  are  made  in  order  to  ac- 
quaint the  students  with  Cleveland  social  agencies  and  social  workers. 

In  the  University  District  students  carry  on  the  usual  activities  of  the 
Visiting  Nurse  Association,  and  the  nursing  work  of  the  Department  of 
Health,  in  which  anti-tuberculosis  work  and  infant  welfare  work  are  in- 
cluded. 

Supervision  in  the  University  District 

To  each  instructor  is  assigned  a  number  of  students,  including  both 
graduate  and  pupil  nurses.  Seven  is  the  maximum  number  of  students 
assigned  to  one  instructor.  Each  student  is  assigned  by  her  instructor  to 
a  subdivision  of  the  district,  and  as  her  knowledge  and  skill  develop,  she  is 
increasingly  held  responsible  for  the  work  in  her  particular  section. 

When  students  begin  their  field  work,  they  are  taken  out  one  at  a  time 
(very  occasionally  two  at  a  time)  by  the  instructor,  who  gives  the  instruction 
in  the  home  and  does  the  work  required,  while  the  student  observes.  A 
thorough  discussion  of  the  visit  follows.  On  a  subsequent  visit  the  roles 
are  reversed,  the  instructor  observing  while  the  student  conducts  the  visit. 
This  procedure  is  repeated  with  different  types  of  visits,  such  as  to  prenatal 
cases,  communicable  disease  cases,  and  so  on,  until  the  student  has  been 
gradually  introduced  to  the  various  types  of  work  usually  encountered  in 
the  district. 

Three  times  daily  the  students  report  at  the  station,  to  receive  assign- 
ments, to  plan  their  work,  and  to  carry  out  the  necessary  office  detail.  An 
opportunity  is  afforded  at  these  times  for  conference  with  the  instructors. 
In  this  way  the  instructor  is  enabled  to  keep  constant  oversight  of  the  stu- 
dents' work,  and  the  students  have  an  opportunity  for  immediate  consulta- 
tion and  advice  upon  problems  arising  in  the  families  they  visit. 

Every  morning  a  conference  is  held  by  the  Director,  which  is  attended 
by  all  the  instructors  and  students.  These  conferences,  in  which  the  students 
take  an  active  part,  constitute  an  invaluable  part  of  the  training.  The 
program  may  consist  of  demonstrations  of  nursing  technique,  instruction  in 
new  procedures,  consideration  of  social  or  other  problems  in  individual 
families,  or  discussion  of  subjects  of  general  professional  interest. 

Students  thus  have  the  benefit  of  demonstrations  given  by  the  instructors 
in  the  homes,  of  direct  supervision   of   their   own  work  in  the  homes,  of  in- 


750  Hospital  and  Health  Survey 

dividual  conference  three  times  daily  with  the  instructor  in  the  office,  and  of 
group  discussion  in  the  morning  conferences.  By  this  careful  teaching  they 
are  enabled  to  derive  the  full  benefit  from  their  experience  in  field  work. 

The  nursing  technic  of  the  students  who  were  observed  gave  evidence 
not  only  of  good  supervision,  but  even  more  important,  it  showed  that  the 
students  had  a  knowledge  of  the  principles  of  hygiene  and  sanitation.  Some- 
times nursing  work  is  done  in  which  the  technic  is  mechanical, — where  the 
nurse  observes  the  details  as  they  were  taught  her  but  does  not  use  intelli- 
gence in  adapting  the  underlying  principles  to  the  special  circumstances  she 
encounters. 

In  the  University  District,  however,  the  reverse  was  found.  In  their 
scrupulous  attention  to  detail  in  the  home,  in  the  beautiful  care  given  the 
patients  even  in  the  most  difficult  surroundings,  in  their  careful  disposal  of 
soiled  linen  and  dressings,  in  their  regard  for  the  patients'  modesty  and 
comfort,  the  students  in  the  University  District  showed  that  their  work 
was  not  merely  a  routine,  but  was  based  on  an  application  of  the  underlying 
principles  of  public  health  and  of  good  nursing. 

School  Nursing 

For  experience  in  school  nursing  students  are  assigned  to  the  Nursing 
Division  of  the  Board  of  Education.  During  the  3  weeks  spent  in  school 
nursing  they  are  expected  not  only  to  observe,  but  also  to  assume  responsi- 
bility under  direction  for  a  part  of  the  work. 

Industrial  Nursing 

The  experience  in  industrial  nursing  consists  mainly  of  observation  in  3 
or  4  factories.  Altogether  12  industrial  concerns  in  Cleveland  are  cooperat- 
ing with  the  University  District  in  offering  the  students  opportunities  for 
observation  and  experience.  It  has  been  possible  for  a  number  of  students 
to  spend  a  week  each  in  observing  the  work  in  the  Goodrich  Tire  Co.  in 
Akron. 

Clinics 

Unusually  ample  facilities  for  observation  and  training  in  clinics  are 
available  for  the  students.  All  students,  except  the  pupils  admitted  for  2 
months  only,  attend  the  following:  Clinic  for  Well  Babies,  Prenatal  Clinic, 
Tuberculosis  Clinic,  and  the  Babies'  Dispensary  (sick  babies). 

In  the  University  District  Health  Center  prenatal  clinics  are  held  twice 
a  week,  and  prophylactic  baby  clinics  three  times.  These  clinics  are  con- 
ducted by  the  instructors  and  attended  by  the  students,  who  thereby  obtain 
valuable  experience  in  clinic  management.  Students  usually  spend  12  hours 
in  all  at  the  Clinic  for  Well  Babies,  and  4  to  6  afternoons  at  the  Prenatal 
Clinic. 

Six  hours  for  3  weeks  are  spent  by  students  at  the  Tuberculosis  Clinic  of 
another  Health  District  (Health  Center  No.  8).  The  hours  of  observation 
are  followed  by  lectures  and  discussions. 


Nursing  751 

Babies'  Dispensary 

An  important  part  of  the  clinic  experience  is  the  training  at  the  Babies' 
Dispensary,  where  the  students  spend  afternoons  for  a  period  of  two  to  three 
weeks.  During  this  time  16  hours  are  devoted  to  lectures  and  discussion, 
of  which  8  are  lectures  on  sick  babies  by  physicians,  and  3  are  classes  in  prac- 
tical work  given  by  the  Superintendent  of  Nurses.  One  hour  each  afternoon 
is  spent  in  reading  the  literature  of  diseases  of  children.  The  practical  work 
consists  of  attending  examinations  during  which  the  cases  are  explained  by 
the  doctors,  and  of  some  supervised  work  in  the  clinics;  of  instruction  in  the 
Social  Service  Department;  and  of  work  in  the  Milk  Laboratory,  where 
modifications  are  taught. 

The  excellent  standards  of  infant  welfare  work  established  by  the  Babies' 
Dispensary  are  reflected  in  the  child  hygiene  work  in  the  University  District. 
The  effectiveness  of  the  teaching  is  shown  by  the  readiness  of  mothers  to 
cooperate  in  preventive  work,  their  ability  to  follow  the  nurses'  directions 
in  milk  modification,  and  their  willingness  to  bring  their  children  to  clinics 
for  observation  as  well  as  for  treatment  in  illness.  It  is  clear  that  the  work 
at  the  Dispensary  constitutes  a  valuable  part  of  the  students'  practical 
training. 

Conclusion 

The  tests  of  public  health  nursing  are  many  and  various, — as  many,  per- 
haps, as  the  types  of  people  and  of  needs  that  are  met.  But  underlying  all 
the  differences  of  race  or  creed,  of  age  or  individuality,  is  the  common  ques- 
tion: How  does  the  public  health  nurse  meet  her  problems?  Not  merely 
how  well  does  she  nurse  this  or  that  patient,  or  how  well  did  she  cheer  this  or 
that  person,  but  what  total  impression  does  she  make  on  her  families,  how 
far  does  she  succeed  in  solving  the  total  family  health  problem?  Has  she 
taught  her  families  anything  of  hygienic  living,  has  she  gotten  their  confi- 
dence, has  she  observed  and  taken  measures  to  deal  with  evidences  of  illness 
or  failures  in  habits  of  health  in  other  members  of  the  family  beside  her  im- 
mediate patient? 

Judged  by  such  standards,  the  course  in  public  health  nursing  has  clearly 
achieved  a  large  measure  of  success.  Various  factors  already  described  have 
operated  to  bring  about  this  result.  Special  recognition  should,  however,  be 
given  to  the  devotion  of  the  professional  staff,  and  to  the  public  spirit  and 
appreciation  of  the  modern  public  health  nursing  movement  which  has  been 
shown  by  the  University  authorities  and  the  lay  committee  who  are  jointly 
responsible  for  this  notable  contribution  to  nursing  education. 

In  general,  then,  the  Course  in  Public  Health  Nursing  is  admirably 
organized  and  highly  effective.  Its  usefulness  could  be  even  further  increased 
by  an  expansion  of  its  staff,  better  office  facilities,  and  ampler  provision  for 
post-partum  service,  in  accord  with  the  following  recommendations. 

RECOMMEND  A  TIONS 

1.     A   full-time   assistant    director    sTiould    be    appointed,    who    should 
share  the  teaching  and  relieve  the  Director  of  part  of  her  routine  duties. 


Hospital  and  Health  Survey 


The  Director  should  thus  be  enabled  to  devote  more  time  to  developing  the 
work,  to  increasing  facilities,  and  to  extending  the  training. 

2.  Another  instructor  should  be  appointed. 

3.  A  private  office  should  be  secured  for  the  Director,  and  additional 
office  space  for  the  instructors  and  students. 

4.  The  number  of  post-partum  cases  nursed  by  each  student  should 
be  increased  as  soon  as  possible. 

5.  In  view  of  the  need  throughout  the  country  for  trained  public 
health  nurses  and  the  exceptional  opportunities  for  training  afforded  in 
Cleveland,  efforts  should  be  made  to  secure  the  greatest  possible  number 
of  students,  and  the  staff  and  teaching  facilities  should  be  sufficient  so  that 
all  qualified  applicants  may  be  admitted.  The  greatest  possible  number  of 
pupil  nurses  should  be  enabled  to  take  the  four  months'  training  in  field 
work. 

INSTITUTE  OF  SCHOOL  HYGIENE 

p*1  The  Institute  of  School  Hygiene,  organized  by  the  Cleveland  Board  of 
Education  with  the  cooperation  of  Western  Reserve  University,  gives  a  six 
weeks'  summer  course  to  graduate  nurses  who  have  had  practical  experience 
in  public  health  nursing.  This  Institute  includes  eminent  experts  from 
various  parts  of  the  country  upon  its  instructing  staff  and  attracts  several 
hundred  students  who  are  enthusiastic  about  the  benefits  derived  therefrom. 
The  course  offered  is  a  real  contribution  to  graduate  nursing  education,  and 
deserves  to  be  generously  supported  so  that  it  may  be  continued  and  ex- 
tended in  future  years. 


Nursing  753 

Public  Health  Nursmgf  in  Cleveland 

INTRODUCTORY 

IN  the  development  of  public  health  nursing  in  the  United  States,  Cleve- 
land has  played  a  leading  part,  various  features  of  which  stand  out  con- 
spicuously for  their  high  degree  of  excellence,  as  standards  set  for  the 
whole  country. 

Among  these  successful  elements,  the  most  conspicuous  are  the  existence 
of  the  Central  Nursing  Committee  for  the  city,  the  concentration  of  activi- 
ties in  a  small  number  of  agencies,  the  development  of  generalized  nursing 
and  the  existence  of  the  Univeristy  Public  Health  Teaching  District. 

Underlying  all  these  activities  and  essential  to  their  success  has  been  the 
unusual  degree  of  interest  and  responsibility  on  the  part  of  the  various 
authorities  and  boards  in  charge,  both  professional  and  lay  members.  With- 
out this  sustained  backing,  the  different  organizations  at  work  could  not 
have  achieved  the  success  of  which,  in  spite  of  various  shortcomings  and 
misdirected  efforts,  the  Nursing  Survey  found  proof  in  its  detailed  appraisal 
of  the  field. 

The  recent  opening  of  the  beautiful  Nurses'  Club  with  its  exceptional 
opportunities  as  a  professional  and  social  center,  illustrates  concretely  the 
appreciation  of  nursing  work  in  Cleveland  and  the  generous  participation  of 
lay  workers  in  the  best  interests  of  the  profession. 

Scope  of  the  Survey 

The  organizations  carrying  on  public  health  nursing  which  were  studied 
by  the  Nursing  Survey  were  the  following:  the  Division  of  Health,  the 
Visiting  Nurse  Association,  the  University  District,  the  School  Nurses,  and 
some  Out-Patient  Departments  of  Hospitals.  Nursing  at  the  Babies'  Dis- 
pensary and  Industrial  Nursing  were  also  studied.  Findings  and  recom- 
mendations as  to  the  work  of  each  agency  are  given  later  in  this  report. 

Our  study  covered  the  details  of  organization  and  administration,  the 
personnel  and  plans  of  work.  In  addition  our  investigators  accompanied 
nurses  into  the  field,  in  the  clinic  and  health  center,  the  school,  factory  and 
home  and  observed  their  personal  contacts  with  individuals  and  families. 
For  by  this  test  obviously  such  work  stands  or  falls.  No  matter  how  well 
planned  and  administered  in  theory,  or  how  lofty  the  aims  and  ambitions  of 
organizations,  they  can  ultimately  be  judged  by  nothing  more  or  less  than 
by  the  performance  of  their  agents  in  the  field,  by  the  success  of  their  efforts 
in  preventive  as  well  as  curative  work. 

The  statistics  of  attendance  at  clinics  or  health  centers,  or  the  number  of 
visits  made  per  nurse  or  district  does  not  tell  the  story  completely  without 
observation  of  the  quality  of  service;  the  success  or  failure  in  teaching  the 
elements  of  hygienic  living  as  well  as  giving  nursing  care,  or  protecting  the 
community  from  disease. 


754  Hospital  and  Health  Survey 

Some  Elements  of  Success 

Common  to  all  the  organizations  studied  is  the  unusually  fine  spirit  of 
the  staffs,  whose  members  almost  without  exception  were  found  conscien- 
tious and  alert.  The  existence  of  the  Central  Nursing  Committee  and  the 
concentration  of  work  in  a  few  organizations  obviously  makes  for  greater 
uniformity  of  method  and  treatment  than  when  diverse  agencies  are  at  work, 
and  lessens  £he  chances  of  duplication  or  misunderstanding. 

The  most  notable  contribution,  however,  made  by  Cleveland  in  the 
public  health  field  is  the  success  of  the  generalized  nursing  system,  demon- 
strated most  completely  in  the  small  University  District,  with  its  high  ratio 
of  nurses  to  population,  by  the  Visiting  Nurse  Association  less  completely 
in  a  larger  area  and  by  the  municipal  staff  so  far  as  it  has  been  adopted  for 
the  city  as  a  whole.  No  other  city  of  its  size  or  larger  has  ventured  to  adopt 
a  generalized  municipal  system.  Few  smaller  cities  have  done  as  much. 
Cleveland  is  thus  leading  the  way  in  one  of  the  most  hopeful  developments 
of  the  modern  public  health  work. 

Value  of  the  Generalized  System 

By  generalized  nursing  is  meant  in  this  report  the  system  by  which  a  com- 
munity is  divided  into  small  districts,  one  nurse  being  assigned  to  each  dis- 
trict to  do  all  the  necessary  varieties  of  nursing  and  of  instruction  inhabits 
of  health  in  that  district. 

In  successful  generalized  nursing,  the  resources  of  the  separate  nursing 
specialties  are  pooled.  Overlapping  of  visits  for  special  purposes  is  elimi- 
nated; overhead  charges  for  maintaining  separate  services  are  reduced.  The 
generalized  nurse,  doing  either  instructive  or  bedside  work,  is  enabled  to 
cover  the  ground,  to  find  new  cases  and  grapple  with  family  problems  as  the 
specialized  nurse  in  many  instances  cannot. 

The  assertion  is  often  made  that  under  the  generalized  plan,  the  special 
needs  of  public  health  work,  such  as  child  hygiene  or  the  care  of  tuberculosis, 
is  neglected  or  less  successfully  carried  on  than  when  the  nurse  is  trained 
along  one  such  line,  and  devotes  herself  exclusively  to  her  one  specialty. 

This  is  a  controversy  of  long  standing;  it  is  undoubtedly  true  that  demon- 
strations of  the  value  of  one  special  service  such  as  the  work  of  the  Ma- 
ternity Centre  Association  in  New  York,  or  of  many  tuberculosis  societies, 
are  of  great  value  in  setting  standards  of  performance  or  in  developing  a 
more  perfect  technic  than  is  often  possible  in  the  excessively  large  districts 
and  with  the  excessive  number  of  patients  carried  by  many  general  visiting 
nurse  associations.  Yet  where  generalized  nursing  has  had  the  fairest  trial 
in  Cleveland,  that  is  in  the  University  Public  Health  District,  where  the 
number  of  nurses  to  copulation  and  the  supervision  of  the  work  is  most 
adequate,  no  branch  of  nursing  appears  to  have  suffered  from  being  merged 
into  the  general  service,  but  has  on  the  contrary  gained.  Where  the  nursing 
has  been  partly  generalized,  that  is  under  the  over  burdened  nursing  service 
of  the  Division  of  Health,  the  bedside  care  of  the  sick  has,  as  we  shall  see, 
been  neglected;  under  the  Visiting  Nurse  Association,  the  instruction  of  the 
family  in  hygienic  habits  has  not  received  sufficient  emphasis. 


Nursing  755 

Obviously,  for  the  success  of  generalized  nursing,  highly  skilled  super- 
vision is  a  prime  requisite.  Direction  by  specialists  must  keep  the  balance 
between  the  various  needs  of  the  different  nursing  specialties.  In  our 
recommendations  for  the  organizations  studied  special  emphasis  has  therefore 
been  laid  on  methods  of  administration  and  supervision. 

Some  Causes  of  Failure 
1.  Inadequate  Numbers  of  Nurses 

Where  failures  were  found  in  the  work  they  were  due,  in  Cleveland  as 
elsewhere,  to  two  main  causes:  insufficient  number  of  nurses  and  inadequate 
or  faulty  supervision.  The  volume  of  work  undertaken  is  far  too  great  for 
the  size  of  the  different  staffs,  and  too  great  for  their  combined  numbers. 

According  to  the  best  opinion  for  a  generalized  service  the  ratio  of  nurses 
to  population  should  be  about  in  proportion  of  one  to  2,000.  In  Cleveland, 
counting  all  but  industrial  nurses,  the  proportion  is  about  one  to  5,228  pop- 
ulation. 

The  distribution  of  nurses  is  as  follows: 

Division  of  Health  (66  at  work  at  time  of  investigation) 80 

Visiting  Nurse  Association _ _ 32 

Board  of  Education : 3 1 

University  District 10 

Total...... 153 

Populat'on,  796,836. 

Ratio,  approximately  1  to  5,228. 

To  reach  the  recommended  figure  of  1  to  2,000  population  the  total 
number  should  be  400  nurses.  To  reach  even  the  ratio  of  1  to  3,000  popula- 
tion, the  total  number  should  be  266,  an  increase  of  113  nurses  over  the  present 
figures. 

With  the  present  shortage,  it  is  manifestly  impossible  to  do  justice  to  all 
phases  of  the  work. 

The  second  main  cause  of  failure  which  disclosed  itself  in  various  of  the 
organizations  studied  is  the  lack  of  adequate  or  correctly  conceived  super- 
vision. Indeed,  supervision  of  the  right  order  proves  itself  to  be  the  crux  of 
public  health  nursing.  It  is  essential  not  only  for  planning  the  work  of  the 
staff  and  coordinating  their  activities  but  as  a  stimulus  and  guide  for  the 
individual  nurse  in  her  function  of  teaching  the  principles  of  health  as  well 
as  giving  bedside  care. 

Supervision  of  the  right  order  means  the  actual  accompaniment  of  nurses 
in  their  home  visiting.  It  brings  to  their  help,  especially  in  the  non-acute 
cases,  where  little  change  is  seen  from  visit  to  visit,  a  fresh  point  of  view,, 
greater  experience,  an  ability  to  see  new  angles  of  old  cases. 


756  Hospital  and  Health  Survey 

Again  and  again,  as  the  following  reports  show,  the  presence  or  lack  of 
intensive  supervision  in  the  different  organizations  studied  discloses  itself 
in  the  quality  of  the  work. 

It  is  for  lack  of  stimulating  direction  that  the  work  of  the  school  nurses 
tends  to  become  routine;  that  the  nursing  service  of  the  Division  of  Health 
tends  to  become  an  extension  of  a  clinical  service,  centered  on  the  clinics, 
rather  than  a  true  public  health  nursing  function,  going  out  into  the  homes. 

The  Central  Committee  on  Public  Health  Nursing 

ONE  of  the  most  valuable  assets  for  public  health  nursing  in  Cleveland 
is  the  existence  of  the  Central  Committee  on  Public  Health  Nursing. 
This  committee  is  probably  unique  among  agencies  for  the  directing  of 
public  health  nursing,  in  its  composition,  and  in  its  influence  in  matters  of 
public  health.  It  is  not  too  much  to  say  that  the  high  rank  of  Cleveland  as 
a'center  for  various  branches  of  public  health  nursing  is  due  in  large  part  to 
the  existence  of  this  committee  and  the  interest  in  public  health  nursing 
which  it  reflects.  To  the  work  of  the  committee  is  to  be  ascribed  the  un- 
usually high  standards  of  the  nurses  in  the  municipal  nursing  services  as  well 
as  in  the  private  organizations. 

Organization 

Several  years  ago  this  Central  Committee  was  created,  representing  each 
of  the  organizations  doing  public  health  nursing  in  the  city,  composed  of  two 
representatives  from  each,  one  of  whom  was  the  superintendent  of  nurses 
and  one  a  trustee,  board  member,  or  executive  officer,  "for  the  maintenance 
of 4 uniform  standards  of  training  and  of  public  health  nursing  throughout 
the^city. " 

The  following  organizations  were  included : 

Division  of  Health  of  the  City  Department  of  Welfare, 

Board  of  Education, 

Babies'  Dispensary  and  Hospital, 

Visiting  Nurse  Association, 

Anti-Tuberculoois  League, 

Western  Reserve  University  Teaching  District. 

Each  organization  selected  its  own  representatives  and  the  whole  group 
chose  a  chairman  and  vice-chairman  who  might  not  be  from  among  its 
members,  but  were  added  to  the  committee,  and  engaged  a  secretary  on  part 
time. 

The  committee  does  not  meet  at  regular  times,  but  whenever  there  is  a 
problem  to  be  studied  and  acted  upon,  perhaps  not  oftener  than  four  or  five 
times  a  year  at  present.  Its  decisions  are  not  binding,  but  are  presented 
in  the  form  of  recommendations  to  the  organizations  represented,  and  have 
almost  invariably  been  voluntarily  approved  and  acted  upon. 


Nursing  757 

Activities 

The  matters  that  have  been  considered  by  the  Central  Committee,  and 
standards  determined  are: 

1.  The  receiving  of  all  nurse  applicants  and  securing  credentials. 

2.  The  passing  on  all  credentials,  accepting  or  rejecting  the  applicant. 

3.  The  assignment  of  applicants  to  the  various  public  health  nursing 
organizations,  and  exchange  of  applicants  from  one  organization  to  another. 

4      Discussion  and  recommendation  of  uniforms. 

5.  Recommending  salary  schedules. 

6.  Study  of  bags  and  equipment. 

The  chairman  of  the  Central  Committee  (always  a  layman)  and  the 
superintendents  of  nurses  form  an  eligibility  sub-committee  which  performs 
the  duties  under  numbers  2  and  3.  All  professional  standards  are  determined 
by  this  sub-committee.  The  assignment  of  applicants  to  the  various  staffs 
is  determined  by  this  sub-committee  on  the  basis  of  first,  expressed  prefer- 
ence of  applicant;  second,  urgency  or  emergency  need;  third,  the  date  on  which 
the  request  for  additional  nurses  was  filed  by  the  superintendent.  There 
has  been  no  dissension  among  the  superintendents  over  the  assignments. 
Nurses  are  told  of  the  work  of  all  agencies  and  allowed  to  express  preference 
if  they  have  any.  They  are  assigned  to  the  agency  of  their  choice  if  there  is 
a  vacancy. 


RECOMMEND  A  TIONS 

The  Central  Committee  has  already  performed  a  notable  service  in  har- 
monizing the  problems  of  personnel,  professional  standards  and  salary 
schedules,  and  it  is  thoroughly  representative  in  its  composition.  But 
additional  factors  must  be  continuously  considered  for  the  effective  growth 
of  public  health  nursing  in  any  city : 

Coordination   of  the   activities   of  the   various   public   health   nursing 
agencies. 

A  well  balanced  development  of  different  types  of  work  in  accordance 
with  a  coherent  program  for  the  city. 

Continuous  study  of  the  expanding  needs  of  the  city,  and  of  new  de- 
velopments in  public  health  nursing. 

Maintenance  of  uniformly  high  standards. 

The  Central  Committee  appears  to  be  the  body  logically  to  be  charged 
with  the  responsibility  for  the  additional  factors  enumerated.  Therefore, 
it  is  recommended  that  the  Central  Committee  assume  the  following  func- 
tions in  addition  to  those  it  already  has,  its  decisions,  however,  as  hereto- 
fore, not  to  be  binding  upon  the  organization  represented. 


758  Hospital  and  Health  Survey 

New  Functions 

1.  Coordinating  all  nursing  agencies  of  the  city  and  obtaining  agree- 
ment among  them  as  to  the  functions  to  be  performed. 

2.  Review  of  all  plans  for  new  projects  or  for  modification  of  current 
programs  of  participating  agencies,  based  on  data  from  the  Welfare  Federa- 
tion. 

3-  Creation  of  several  sub-committees  for  research  and  consideration 
of  special  professional  problems.     Some  of  these  might  be  for  the  present: 

Prenatal  and  maternity  service, 

Industrial  nursing, 

Generalized  nursing. 

4.  A  campaign  to  recruit  students  for  training  schools  and  graduate 
nurses  for  public  health  nursing. 

5.  Adding  to  personnel  representatives  from  the  Chamber  of  Com- 
merce and  industrial  nurses,  and  placing  them  with  others  on  a  sub-committee 
on  industrial  nursing. 

6.  Adding  to  personnel  representatives  from  the  proposed  Obstetrical 
Council  and  placing  them  with  others  on  the  sub-committee  on  prenatal 
and  maternity  service. 

7.  Appointment  of  a  sub-committee  to  advise  with  the  Division  of 
Health,  and  with  its  permission  to  supervise  the  proposed  extension  district. 

Division  of  Health  Nursing  Service 
Scope  of  the  Work 

THE  nursing  service  of  the  Division  of  Health  covers  a  wide  range  of 
activities  including  nearly  every  form  of  public  health  nursing  coming 
within  the  range  of  any  municipal  health  department's  functions  and 
many  more  than  are  usually  undertaken  by  municipalities.  Starting  with 
the  prevention  of  communicable  diseases  in  1909,  the  service  has  been. ex- 
tended year  by  year  until  it  now  includes  eight  branches  of  public  health 
nursing,  as  follows: 

Undertaken  in 

Prevention  of  communicable  diseases _ 1909 

Tuberculosis  work ., 1910 

Infant  Hygiene 1911 

Prevention  of  Blindness _ 1912 

Regulation  of  Midwifery „ 1912 

Supervision  of  Boarding  Homes  for  Babies _ _.     ,,  ,.  1913 

School  Nursing  in  the  Parochial  Schools 1917 

Prenatal  Nursing _— ~  1918 


Nursing  759 

These  services" were  maintained  as  separate  units,  each  with  its  own  staff 
of  nurses,  until  early  in  1917  when  the  separate  staffs  were  combined  into  one, 
the  field  divided  into  smaller  districts,  and  each  nurse  assigned  a  district  and 
held  responsible  for  all  kinds  of  work  within  that  district.  Cleveland  is  to 
be  congratulated  on  its  advanced  stand  in  thus  adopting  a  generalized  muni- 
cipal nursing  system. 

The  Present  Staff 

The  present  staff  (March,  1920)  consists  of  an  assistant  director,  three 
special  supervisors,  seven  field  supervisors  and  seven  assistant  field  super- 
visors, in  addition  to  a  field  staff  of  66  nurses.  There  are  two  stenographers 
at  each  of  the  seven  Health  Centers  and  the  Nursing  Service  shares  the  use 
of  several  at  the  main  office  in  the  City  Hall. 

Analysis  of  Activities 

Communicable  Diseases 

In  seven  districts  sanitary  officers  place  and  remove  placards  on  houses 
in  which  there  is  a  contagious  disease.  In  these  seven  districts  the  nurses 
visit  patients  having  scarlet  fever  and  diphtheria. 

In  the  remaining  district' (District  number  1)  the  nurses  do  the  placing 
and  removing  of  placards  and lyisit|  patients  having  contagious  diseases 
which  are  placarded  as^follows: 

Cerebro  spinal  meningitis, 

Infantile  paralysis 

Diphtheria, 

Scar'et  fever, 

Whooping  cough, 

Measles, 

Chickenpox, 

Typhus  fever, 

Cholera, 

Plague, 

Leprosy. 


Diseases  rarely  occurring  in  Cleveland. 


In  none  of  the  districts  do  the  nurses  visit  smallpox  patients  or  families 
from  which  a  smallpox  case  has  been  removed. 

The  nurse's  duties  include  explanation  of  the  sanitary  code;  the  establish- 
ment of  isolation  of  the  patient  and  instruction  of  the  family  concerning  the 
maintenance  of  isolation;  the  establishment  of  quarantine.  The  nurse  also 
determines  what  persons  are  to  have  permits  to  leave  the  house  and  she 
issues  the  permits;  she  takes  release  cultures  unless  the  doctor  on  the  case 
prefers  to  do  so  himself;  arranges  for  hospital  care  for  the  patient  and  the 
giving  of  nursing  care. 


760  Hospital  and  Health  Survey 

Conversation  with  the  nurses  and  supervisors  and  study  of  the  records 
leads  to  the  strong  impression  that  attention  is  largely  focussed  on  the  issu- 
ing of  permits  and  the  time-consuming  taking  of  cultures,  rather  than  on  the 
care  of  the  patient,  the  instruction  of  the  family  in  caring  for  him,  or  on 
measures  for  their  own  protection.  "Nursing  care  is  rarely  given,"  is  the 
unanimous  opinion  of  both  nurses  and  supervisors  because  in  their  estima- 
tion, "it  isn't  needed." 

Typhoid  patients  have  been  visited  only  since  the  fall  of  1919  and  then 
only  for  the  purpose  of  filling  out  a  questionnaire  in  the  attempt  to  trace  the 
source  of  infection.  No  attempt  is  made  to  care  for  the  patient,  to  teach 
the  members  of  the  family  how  to  care  for  him,  nor  how  to  protect  them- 
selves. Neither  is  any  effort  made  to  see  that  the  patient  has  such  care; 
only  5  cases  out  of  165  came  to  the  attention  of  .the  Visiting  Nurse  Associa- 
tion last  year. 

Pneumonia  cases  are  not  visited  or  reported  to  the  Visiting  Nurse  Asso- 
ciation to  be  visited. 

Outside  of  Districts  I.  and  VIII.,  no  attention  is  paid  to  measles  or 
whooping  cough.  While  from  the  point  of  view  of  checking  the  spread  of 
a  contagious  disease  it  may  be  futile  to  do  more  than  to  placard  these  dis- 
eases, from  the  point  of  view  of  the  future  health  of  the  patients,  instruction 
in  nursing  care  and  supervision  are  badly  needed  to  prevent  the  frequent, 
serious  and  often  fatal  sequelae.  Such  oversight  and  care  could  be  given  by 
the  staff  of  the  Visiting  Nurse  Association. 

Tuberculosis 

Scope: 

The  tuberculosis  work  includes  the  maintenance  of  35  tuberculosis 
clinics  a  week,  and  the  follow-up  work  in  the  home.  Every  patient  who  comes 
to  a  clinic  is  visited  in  his  home  and  if  his  case  is  positive  or  cannot  be  satis- 
factorily diagnosed  he  is  "carried  on  the  books"  and  visited  occasionally, 
if  the  doctors  are  willing.  All  cases  reported  as  positive  by  doctors  and  all 
patients  whose  sputum  has  been  sent  in  for  analysis  are  visited.  Likewise, 
all  patients  referred  to  the  Hospital  Admission  Bureau  to  be  sent  to  the 
City  Hospital,  the  State  Hospital  or  Warrensville,  and  all  suspicious  or 
positive  cases  referred  by  other  nursing  or  social  agencies  are  visited. 

Plan: 

Unless  they  attend  the  clinic  regularly,  an  effort  is  made  to  visit  all  these 
patients  once  a  month  to  give  detailed  instruction  in  treatment  of  the  pa- 
tient and  prophylaxis.  Nursing  care  is  supposed  to  be  given  to  all  those 
in  need  of  it  who  are  unable  to  pay  seventy-five  cents  a  visit.  Those  able 
to  pay  this  amount  are  supposed  to  be  referred  to  the  Visiting  Nurse  Asso- 
ciation, but  only  51  cases  were  cared  for  by  the  Visiting  Nurse  Association 
between  October,  1918,  and  October,  1919.  The  statement  is  made  that 
there  is  little  need  of  nursing  care.  It  is  intended  to  have  the  whole  family 
and  other  persons  who  have  been  exposed,  especially  the  children,  examined 
at  the  Health  Center  or  by  a  private  doctor.     If  a  very  suspicious  or  posi- 


Nursing  761 

tive  case  fails  to  return  to  the  clinic,  a  form  letter  is  sent.  If  there  is  no 
response  a  second  is  sent  containing  a  threat  to  send  an  officer  after  the 
patient.  This  is  often  efficacious,  but  if  it  brings  no  response,  the  officer  is 
sent.     Apparently  this  method  is  used  with  some  frequency. 

Performance: 

While  diagnosis  and  instruction  at  the  clinic  and  the  effort  to  secure 
clinic  attendance  are  emphasized,  study  of  the  home  conditions,  the  arrange- 
ment for  prophylactic  mode  of  living  at  home,  careful  instruction  and  nurs- 
ing care  are  inadequate  and  home  visits  are  far  too  infrequent.  Nursing  care 
is  rarely  given.  The  nurses  do  not  have  time  to  hunt  up  incipient  or  ad- 
vanced unreported  or  undiagnosed  cases. 

The  records  show  that  there  is  an  average  of  about  100  tuberculous 
patients  to  each  nurse.  The  reports  show  that  in  one  month  the  average 
number  of  visits  made  by  the  nurses  to  patients  tuberculous,  suspicious  and 
non-positive  was  .47  per  patient. 

In  a  second  month  it  was  .64  per  patient.  The  supervisors  stated  that 
it  was  not  possible  to  visit  even  the  positive  cases  once  a  month,  and  the 
suspicious  and  contact  patients  were  visited  at  intervals  varying  from  two 
to  six  months.  The  records  verify  these  statements.  It  is,  therefore,  evi- 
dent that  the  patients  are  not  seen  frequently  enough  for  effective  curative 
or  preventive  work,  and  that  little  attention  can  be  given  to  securing  exami- 
nation of  the  family  and  others  exposed.  There  is  no  easily  applied  check 
in  the  records  to  show  the  frequency  of  clinic  attendance  and  home  visits. 
Nor  is  there  any  study  of  the  sources  from  which  the  cases  come  to  reveal 
areas  of  the  city  which  should  be  brought  under  surveillance. 

In  accompanying  nurses  in  their  districts  much  time  was  lost  in  attempt- 
ing to  locate  some  tuberculous  patients  who  had  moved  away  a  month 
before.  If  the  nurses  were  able  to  call  on  their  patients  more  frequently  it 
would  be   easier  to  keep  in  touch  with  them  when  they  moved. 


Child  Hygiene 

Scope: 

This  service  included  the  maintenance  of  well  baby  clinics  at  13  prophy- 
lactic stations;  follow-up  visiting  of  these  babies  in  the  homes;  visiting  all 
babies  attending  the  Babies'  Dispensary  and  Hospital;  visiting  all  babies 
whose  births  are  reported,  and  visiting  babies  discovered  in  the  course  of 
routine  work  in  the  districts  or  reported  by  doctors  and  neighbors. 

Performance: 

From  the  records  it  appears  that  each  nurse  has  under  supervision  an 
average  of  about  200  babies.  Study  of  the  records  shows  that  an  average 
of  .4  visits  is  paid  each  baby  each  month;  that  is,  each  baby  is  visited  about 
once  in  every  2  to  2^  months.  One  in  every  9  babies  comes  to  the  clinic 
once  during  the  month. 


762  Hospital  and  Health  Survey 

Attention  is  largely  concentrated  on  feeding  of  babies;  instruction  in 
infant  hygiene  both  at  the  clinic  and  in  the  home  is  somewhat  neglected. 
Home  visits  are  too  infrequent  and  irregular.  From  the  records  it  appears 
that  nursing  care  is  rarely  given  and  then  very  inadequately.  These  condi- 
tions are  due  to  the  fact  that  the  nurses  have  too  large  a  number  of  patients 
per  nurse  to  care  for. 

Yet  individual  instances  of  good  home  visiting  were  found.  Thus,  in 
accompanying  one  nurse  in  a  visit  to  the  mother  of  twin  babies,  the  investi- 
gator was  impressed  with  the  nurse's  sympathy  and  good  teaching.  With 
three  older  children  and  a  husband  to  take  care  of,  the  mother,  herself  half 
sick,  had  prepared  the  babies'  milk  modification  excellently,  and  showed  the 
results  of  thorough  instruction.     She  brightened  at  the  nurse's  entrance. 

Prevention  of  Blindness 

Baby  eye  work  was  done  by  the  Babies'  Dispensary  and  Hospital  until 
January,  1917.  At  that  time  it  was  turned  over  to  the  Division  of  Health. 
It  was  done  at  first  by  a  special  group  of  nurses  until  August,  1919,  and  was 
then  put  into  the  general  service. 

Nurses  are  sent  to  care  for  ophthalmia  neonatorum  cases  the  same  day 
they  are  reported,  and  they  try  to  return  as  often  as  necessary.  Where  the 
case  is  acute  and  home  care  inadequate  it  is  sent  with  its  mother  to  the  hos- 
pital. 

There  are  no  figures  to  show  the  number  of  such  cases  or  the  care  given. 
The  opinion  of  the  director  of  the  staff  is  that  it  is  well  done. 

Trachoma  is  a  reportable  disease  and  all  cases  reported  by  doctors  or  by 
the  Board  of  Education  are  visited  by  the  nurses. 

Midwife  Supervision 

This  work  is  entirely  under  the  control  of  a  special  supervisor.  There 
are  160  licensed  midwives  and  110  practising  without  licenses.  The  licensed 
midwives  are  visited  in  their  homes  at  irregular  intervals  for  the  purpose  of 
giving  them  instruction  in  prenatal  and  infant  hygiene,  technic,  and  exami- 
nation of  their  bags  and  stubs.  Some  are  visited  frequently;  some  not 
oftener  than  once  a  year.  They  are  not  supervised  during  delivery,  nor 
do  they  receive  demonstrations.  There  is  little  time  or  opportunity  for  the 
discovery  of  illegal  practitioners.     Much  more  frequent  visits  are  necessary. 

(For  further  discussion  of  the  midwife  situation  see  report  on  child 
health  work,  Part  III.) 

Supervision  of  Boarding  Homes 

The  nurses  are  supposed  to  visit  each  home  in  which  babies  are  boarded 
out  under  license  from  the  State  Board  of  Charities  and  to  send  a  report  to 
the  Humane  Society.  There  are  no  records  to  show  the  frequency  of  these 
visits  or  the  thoroughness  of  the  work  done.  All  these  babies  get  special 
milk  free  from  the  Health  Center,  and  the  matron  is  expected  though  not 
compelled  to   bring  the  babies  to  the  Health  Center  regularly. 


Nursing  763 

A  visit  to  a  boarding  home  with  one  of  the  nurses  in  the  course  of  our 
investigation,  gave  evidence  of  good  home  teaching.  The  baby  was  anaemic, 
with  an  acute  vaginitis,  had  broken  places  on  lips  and  irritation  of  mucous 
membrane  in  mouth,  the  latter  indicating  a  probable  digestive  disturbance. 
Instructions  in  regard  to  vaginal  care  evidently  had  been  very  good,  for  the 
trouble  was  clearing  up  rapidly. 

Parochial  School  Nursing 

In  March,  1917,  the  Division  of  Health  Nurses  undertook  some  work  in 
17  Parochial  Schools,  increasing  to  21  schools  for  the  school  year  1918-1919. 
9323  pupils  in  these  schools  received  one  physical  inspection  (by  a  nurse 
alone).  In  addition  to  sending  a  note  to  the  parents,  an  effort  was  made  to 
follow  up  all  children  found  to  have  defects.  No  tabulation  has  been  made 
to  show  what  percentage  of  defects  the  nurses  succeeded  in  having  cor- 
rected. Incomplete  as  this  service  was,  it  consumed  a  good  deal  of  time  and 
effort,  and  no  doubt  certain  appreciable  results  were  obtained. 

For  the  school  year  1919-1920  all  the  remaining  parochial  schools  were 
added  to  the  list  making  a  total  of  68  with  a  school  population  of  approxi- 
mately 35,000.  To  have  carried  on  the  work  at  all  for  so  many  schools 
would  have  consumed  the  full  time  of  at  least  twelve  nurses  and  twice  that 
number  would  be  needed  to  get  real  results.  As  the  entire  field  staff  of  the 
Nursing  Service  averaged  only  about  50,  it  was  obviously  impossible  to  de- 
vote the  necessary  time  to  school  nursing  in  addition  to  the  many  other 
heavy  duties.  No  attempt  was  made,  consequently,  to  carry  out  the  pro- 
gram of  the  previous  year.  A  single  observation  was  made  of  each  school 
room  full  of  pupils  to  discover  any  evidences  of  contagious  disease.  A  visit 
was  undertaken  once  a  week  to  each  school  to  get  a  list  of  absentees  and  to 
give  the  sisters  an  opportunity  to  consult  the  nurse  about  any  special  cases. 
The  nurses  undertook  to  visit  as  many  as  possible  of  the  children  who  were 
seldom  absent  or  whose  absence  was  not  explained. 

Such  work  cannot  be  called  school  nursing.  Until  the  staff  can  be  in- 
creased to  devote  the  equivalent  of  the  full  time  of  twelve  nurses  to  this 
service,  it  would  seem  better  to  concentrate  all  the  work  in  a  few  schools 
(those  in  one  district)  where  it  can  be  done  intensively  and  adequately. 

Prenatal  Nursing 

The  extension  of  advice  and  supervision  to  all  prenatal  patients  except 
those  under  care  of  a  private  physician  was  undertaken  in  1918.  Those 
unable  to  have  a  private  doctor  were  carried  until  visited  by  the  out-patient 
nurse  from  St.  Luke's  or  from  the  Cleveland  Maternity  Hospital.  No  definite 
routine  has  been  established  and  no  attempt  is  made  to  do  urinalysis  or  take 
blood  pressure. 

Little  effort  has  been  made  to  work  up  this  service,  the  nurses  frankly 
admitting  that  they  have  too  much  to  do  to  undertake  this  additional  bur- 
den. Less  than  one  visit  per  month  is  paid  each  prenatal  patient.  Tho- 
rough work  (according  to  the  standard  of  the  New  York  Maternity  Center) 


764  Hospital  and  Health  Survey 

is  not  undertaken.  Again  until  the  staff  can  be  augmented  in  sufficient 
numbers  to  make  thorough  work  possible,  it  would  seem  advisable  to  dis- 
continue this  service  except  for  one  district  and  in  that  district  to  make 
it  a  part  of  the  city-wide  service  elsewhere  described. 

Analysis  of  Administration 

Organization 

The  chart  of  organization  of  the  Division  of  Health  places  the  Nursing 
directly  under  the  Commissioner's  office,  serving  all  bureaus  as  needed  and 
directly  under  his  control.  For  budget  purposes  the  nurses  are  distributed 
among  the  bureaus  of  Child  Hygiene,  Communicable  Disease,  and  Tuber- 
culosis. As  a  matter  of  fact  there  is  a  single  staff  of  nurses  doing  general- 
ized work  under  one  director,  who  is  responsible  to  the  Commissioner. 

Headquarters  Staff 

At  present  the  staff  at  Headquarters  consists  of:  Director  of  Nurses, 
Assistant  Director  and  three  Special  Supervisors,  one  having  supervision  of 
parochial  schools,  one  of  eye  work  and  midwifery.  The  third  is  responsible 
for  various  duties,  compiling  the  monthly  statistical  reports,  such  as  bi- 
weekly Health  Center  staff  meetings,  visiting  nurses  who  are  sick,  and  per- 
forming several  other  odd  duties. 

The  work  is  so  arranged  at  headquarters  that  none  of  the  staff  are  charged 
with  responsibility  for  analyzing  the  character  and  results  of  the  work,  for 
studying  the  needs  and  personalities  of  the  staff  and  developing  them  for 
promoting  true  leadership  in  supervision  and  for  extracting  the  maximum 
value  of  generalized  work  through  building  up  family  health  work.  The 
headquarters  staff  instead  are  engaged  in  more  or  less  routine  duties  which 
give  them  no  time  or  opportunity  for  these  broader,  fundamental  duties. 

The  absence  of  a  special  office  for  the  director  tends  to  immerse  her 
constantly  in  unimportant  details  that  should  be  carried  by  others. 

Staff  at  Health  Centers 
Spirit  of  Staff 

The  present  staff  at  each  Health  Center  consists  of  a  nurse  supervisor 
and  an  assistant  supervisor  and  from  6  to  12  field  nurses. 

Each  center  has  a  fine  spirit  of  team  work  and  loyalty  The  helpful, 
generous  cooperation  of  nurses  and  supervisors  calls  for  commendation. 
The  cooperation  between  the  Health  Centers  and  other  social  agencies  is 
close  and  productive  of  good  results.  In  discussing  their  cases,  the  nurses 
have  their  information  well  in  hand,  and  are  not  easily  confused. 

The  spirit  of  the  work  cannot  be  criticized;  on  the  contrary,  the  spirit  of 
service  that  dominates  the  work  is  admirable.  All  of  the  supervisors  and 
nurses  who  were  seen  are  evidently  working  very  hard  and  against  the  odds 
of  having  too  much  to  do,  and  of  trying  to  do  it  without  carefully  organized 
plans. 


Nursing  765 

Organization  of  work 

The  large  burden  of  administrative  detail  put  on  the  supervisors  when 
they  were  given  charge  of  the  Health  Centers  has  developed  a  faulty  system 
of  supervision.  The  supervisors  and  their  assistants  spend  practically  all 
their  time  within  the  Centers,  and  have  virtually  become  Health  Center 
Managers.  The  assistant  supervisors  were  appointed  with  a  view  to  re- 
lieving the  supervisor,  to  enable  her  to  devote  more  time  to  the  instruction 
of  the  nurses.  The  assistants,  however,  have  also  been  absorbed  in  the 
administrative  detail  of  the  Center,  without  noticeably  relieving  the  super- 
visor. This  means  neglect  of  one  of  the  primary  needs,  the  supervision  and 
teaching  of  nurses  in  the  homes,  without  which  generalized  service  is  not 
successful. 

Thus,  for  instance,  sufficient  care  is  not  given  to  fitting  nurses  into  their 
districts.  One  nurse  accompanied  by  our  investigator  in  her  home  visits 
proved  to  be  totally  out  of  sympathy  with  the  Polish  people  in  her  district 
and  their  apparent  stolidity.  She  is  enthusiastic  over  the  Italians.  With 
better  supervision  she  might  be  transferred  to  another  district;  her  approach 
to  her  people  might  be  improved. 

Again,  in  another  visit  the  need  of  instructing  the  nurses  in  their  home 
visits  was  well  illustrated.  Here  the  last  culture  of  a  little  girl  who  had  been 
ill  with  diphtheria  had  proved  negative.  She  was  of  no  further  interest  to 
the  nurse,  though  looking  pale  and  sick.  "There  is  no  use  trying,  the  mother 
is  ignorant, "  was  her  response  to  a  suggestion  about  the  little  girl's  health. 

Various  times  in  the  investigator's  presence,  a  nurse  consulted  the  super- 
visor at  the  Health  Center  concerning  difficult  tuberculosis  cases,  usually 
concerning  refusal  of  patients  to  go  to  the  sanatorium.  Each  time,  the 
case  seemed  to  the  investigator  sufficiently  serious  to  warrant  a  visit  to  the 
home  by  the  supervisor  in  order  to  confirm  the  nurse's  findings.  The  super- 
visor, however,  had  either  no  time  or  no  inclination  to  do  more  than  advise 
the  nurse  at  the  Center. 

In  Center  routine,  each  supervisor  has  a  different  method.  Yet  this 
work  can  be  systematized  without  in  any  way  destroying  the  initiative  of 
the  supervisor.  The  supervisors  appear  tired  and  worried  by  their  respon- 
sibility. Two  of  them  have  recently  had  extended  leaves  of  absence  owing 
to  illness.  This  is  probably  due  as  much  to  lack  of  system  as  to  too  much 
work.  The  burden  of  administrative  detail  could  be  lightened  without  giv- 
ing up  any  supervisory  functions.  Much  of  the  management  of  the  Center 
could  be  better  done  by  an  experienced  office  manager. 

The  nurses'  time  in  the  Center,  which  should  be  devoted  to  consultation 
with  the  supervisor,  telephoning  doctors  and  other  agencies,  and  record 
work,  is  very  much  interrupted  by  affairs  of  the  Health  Center. .  Clinics  are, 
for  instance,  often  held  in  the  same  room. 

Lack  of  Supervision  of  Nurses  in  the  field 

The  nurse  is  well  supervised  in  clinic  procedure,  and  she  is  free  to  confer 
with  the  supervisor  on  her  troublesome  cases.  The  routine  method  of  dis- 
missing cases  only  after  careful  consideration  by  the  supervisor  and  on  her 


766  Hospital  and  Health-  Survey 

approval,  is  excellent.  In  the  field,  however,  the  nurse  works  alone;  it  is 
only  when  a  definite  problem  has  developed  that  the  supervisor  accompanies 
her. 

In  but  one  of  the  Centers  is  there  any  effort  on  the  part  of  the  supervisor 
to  go  over  a  nurse's  cases  with  her  regularly,  to  remove  the  closed  cases,  and 
to  check  upon  the  frequency  of  visits.  The  supervisor  checks  up  the  nurse's 
work  by  reading  her  dictation,  or  by  laboriously  going  over  her  charts  in  the 
general  file. 

There  appears  to  be  a  tendency  to  shift  the  emphasis  in  health  work 
from  the  home  to  the  Health  Center,  and  to  make  the  visits  to  the  Center, 
on  the  part  of  the  patients,  the  end  and  object  of  all  the  work. 

While  the  majority  of  the  supervisors  expressed  the  wish  that  more  home 
visiting  with  nurses  were  possible,  apparently  few  of  them  realized  what  this 
should  mean.  Indeed,  several  stated  that  little  home  visiting  was  neces- 
sary since  they  trusted  their  nurses.  Several  others  felt  that  only  where 
definite  home  problems  existed,  supervision  of  home  work  was  necessary. 

There  appears  to  be  little  realization  of  the  need  of  supervision  of  non- 
acute  cases,  where  no  obvious  problems  exist,  but  where  adequate  direction 
is  essential  for  constructive  public  health  nursing.  Many  health  problems 
are  obscure.  The  nurse  in  a  continual  rush  of  work  is  apt  to  get  into  a  rut, 
and.,  unsupervised,  to  follow  the  path  of  least  resistance.  The  experienced 
eyes  of  a  supervisor  are  essential  for  a  fresh  point  of  view.  This  is  especially 
true  of  the  subtle  or  non-acute  cases  that  constitute  a  majority  of  the  Di- 
vision of  Health  calls.  These  patients,  where  little  change  is  seen  from 
visit  to  visit,  call  for  greater  skill,  quicker  perceptions,  more  alertness,  than 
do  those  requiring  only  bedside  care.  Such  skill  and  perception  and  alert- 
ness are  stimulated  by  personal  visits  of  the  supervisor,  which,  when  done 
in  the  proper  spirit,  are  welcomed  by  the  nurse. 

The  number  of  supervisors  and  clerical  assistants  is  not  too  small.  One 
director  of  nurses,  ten  supervisors,  seven  assistant  supervisors,  at  least  four- 
teen full-time  stenographers,  are  now  available,  yet  both  supervisors  and 
nurses  seem  to  be  submerged  in  the  mechanical  details  of  the  work.  The 
average  number  of  nurses  per  supervisor  is  unusually  low  for  such  a  large 
group. 

With  the  addition  of  an  office  manager  and  a  possible  curtailment  of  the 
administrative  work  in  the  Centers,  it  would  be  possible  for  the  supervisor 
to  spend  at  least  half  of  every  day  in  the  districts.  If  a  careful  analysis  were 
made  of  the  activities  of  the  supervisor  and  her  assistant,  recording  every 
detail  of  their  work  for  a  definite  length  of  time,  many  duties,  now  con- 
sidered essential,  could  be  eliminated  or  shifted  to  others,  thereby  allowing 
the  supervisor  time  to  make  home  visits  with  the  nurses.  It  should  be  pos- 
sible to  divide  the  clinic  work  between  three  persons, — the  supervisor,  the 
clinic  nurse,  and  the  office  manager.  Well  trained  volunteers  might  also  be 
helpful  in  clinics. 


N  UBSING  767 

Record* 

In  spite  of  the  fact  that  in  every  Center  but  one,  the  supervisor,  her 
assistant,  and  two  full-time  stenographers  spend  practically  all  their  time 
in  clerical  and  administrative  work,  the  nurses  find  it  necessary  to  spend  an 
average  of  two  hours  daily,  out  of  their  seven-hour  day,  in  work  in  the  Center. 
Observation  might  possibly  show  the  time  so  spent  to  be  even  greater, 
especially  in  the  Centers  where  the  nurses  return  at  noon  or  at  four  o'clock 
for  new  calls.  There  is  only  one  Center  of  which  this  statement  does  not 
hold  true.  Much  of  this  time  is  taken  up  in  clerical  work.  A  simplified  and 
coordinated  system  of  records  would  eliminate  a  large  amount  of  this  routine 
work. 

The  compilation  of  the  monthly  statistical  reports  is  a  very  difficult  task 
because  of  the  cumbersome  and  confused  method  of  reporting.  The  record 
system,  having  been  developed  piecemeal  and  service  by  service,  is  far  from 
coherent.  Many  figures  are  gathered  which  serve  no  useful  purpose,  and 
figures  necessary  for  a  proper  appraisal  of  the  work  and  an  accurate  measure- 
ment of  results  are  not  obtainable.  An  altogether  unjustifiable  amount  of 
the  nurses'  time,  both  at  the  City  Hall  and  in  the  Health  Centers,  is  con- 
sumed in  keeping  up  this  complex  and  voluminous  system  of  bookkeeping. 
Reorganization  is  needed,  but  it  is  doubtful  whether  anyone  in  the  Division 
of  Health  is  qualified  to  evolve  a  properly  simplified  method  of  record  keep- 
ing. An  expert  should  be  engaged  to  reorganize  the  system,  both  in  the 
City  Hall  and  the  Health  Center,  and  thus  save  valuable  time  now  being- 
was  ced  in  unnecessary  clerical  work.  The  proper  person  to  provide  forms, 
to  organize  records  and  to  analyze  the  tabulated  information  received  through 
the  nurses'  reports,  would  be  the  statistician  of  the  Division  of  Health,  as 
proposed  in  the  chapter  on  Vital  Statistics. 

After  such  a  system  had  been  installed  it  should,  so  far  as  possible,  be 
turned  over  to  an  office  manager.  It  is  highly  desirable  that  such  an  office 
manager  be  appointed  in  the  office  at  the  City  Hall  and  one  at  each  Health 
Center,  to  whom  the  greater  part  of  the  detail  work  could  be  shifted  in  order 
that  the  supervisors  may  have  an  opportunity  to  attend  to  their  more  im- 
portant duties  of  direction. 

The  laborious  work  now  spent  in  keeping  the  milk  book — to  mention 
only  one  instance — could  be  turned  over  at  once  to  the  office  manager. 


The  Staff  of  Field  Xerses 

Abundant  evidence  is  available  to  show  that  the  nurses  are  heavily  over- 
loaded with  work  and  are  carrying  far  too  many  patients  per  nurse,  and 
covering  too  large  a  territory  to  do  effective  work.  They  average  260  fam- 
ilies each.  The  number  is  considerably  higher  when  estimated  by  indi- 
viduals. They  are  overburdened  with  the  intricacies  of  the  complicated 
record  system  and  the  large  amount  of  time  spent  in  the  clinics  leaves  in- 
sufficient time  to  develop  home  visiting.  As  a  result,  the  nurses  are  often 
discouraged.  The  average  number  of  home  visits  is. over  300  per  nurse  per 
month.     The  patients  scarcely  receive  an  average  of  one  visit  per  month. 


768  Hospital  and  Health  Survey 

The  nurses  are  doing  their  best  under  this  accumulation  of  overwork,  but 
cannot  be  expected  to  obtain  substantial  results  when  they  are  able  to  give 
so  little  attention  to  constructive  teaching  to  patients  in  their  homes. 

New  Nurses 

New  nurses  do  not  receive  proper  introduction  to  their  work.  They  are 
sent  out  with  another  nurse"  for  a  day  or  two  and  receive  only  such  instruc- 
tion as  a  very  busy  Supervisor  can  find  time  for  in  the  Health  Center.  No 
other  instruction  is  given.  The  character  of  the  nurse's  work  is  not  studied, 
her  weaknesses  found  and  methods  of  correction  pointed  out,  nor  is  there 
any  way  of  developing  the  abilities  of  a  nurse.  No  efficiency  records  are 
kept.  Such  a  record  should  not  only  analyze  the  nurse's  ability  and  work, 
but  it  also  should  demonstrate  the  supervisor's  ability  to  know  the  nurses, 
to  fit  them  into  districts,  to  develop  strong  points  and  to  direct  enthusiasm 
and  energy  into  proper  channels.  The  record  of  the  nurse  should  be  dis- 
cussed by  the  Center  supervisor  and  the  director  of  nurses,  and  the  nurse 
put  into  the  district  she  can  best  serve.  At  present  the  supervisors  have  no 
regular  method  of  trying  to  fit  the  nurse  to  the  district.  If  it  is  apparent 
that  she  is  not  getting  cooperation,  she  is  transferred,  but  this  happens  in- 
frequently. 

Uniforms 

The  nurses  wear  any  kind  of  street  clothes  they  choose.  They  go  in  and 
out  of  district  homes  giving  nursing  care  in  suits  and  woolen  dresses.  This 
is  not  only  exceedingly  bad  practice  but  detracts  from  the  usefulness  of  the 
nurse,  since  she  is  not  readily  recognizable  as  a  nurse  while  at  work  in  the 
district,  and  her  costume  is  not  suitable  for  giving  nursing  care. 

Probably  one  reason  that  so  little  actual  nursing  occurs  is  the  fact  that 
the  nurses  do  not  wear  uniforms.  Even  though  they  are  protected  by  a 
gown,  they  are  over  cautious  in  approaching  the  bedside  of  a  contagious  or 
infectious  case.  If  effective  work  is  to  be  done  in  home  visiting,  teaching 
by  actual  example  must  take  place,  and  this  cannot  in  wisdom  occur  unless 
the  nurse  is  in  a  washable  uniform.  Moreover,  the  smart  uniform  adds  to 
the  dignity  and  impressiveness  of  the  nurse. 

GENERAL  CONCLUSIONS 

The  principles  and  plans  of  the  Nursing  Service  of  the  Division  of  Health 
are,  in  general,  excellent.  Its  performance,  however,  does  not  equal  its 
ideals,  mainly  because  it  has  not  increased  its  staff  sufficiently  to  carry  the 
ever  increasing  volume  of  work.  The  majority  of  its  shortcomings  can  be 
laid  at  the  door  of  the  insufficiency  of  numbers.  The  rest  are  due  to  a  top- 
heavy  plan  of  management  and  insufficient  supervision. 

At  present  emphasis  centers  around  attendance  at  Health  Centers,  diag- 
nosis and  prescription  for  treatment.  The  nursing  service  is  in  reality  an 
extension  of  a  clinical  service  rather  than  a  true  public  health  nursing  serv- 
ice. Home  visiting  is  an  adjunct  rather  than  the  prime  activity  of  the  nurse. 
What  is  needed  is  greater  frequency  of  visits  in  the  home,  and  also  longer 


Nursing  769 

visits  so  as  to  enable  the  nurses  to  pay  more  careful  attention  to  the  health 
of  the  family,  to  the  teaching  of  hygienic  habits,  and  the  giving  of  nursing 
care. 

A  Proposed  Extension  District 

In  order  to  afford  an  opportunity  for  the  city  to  extend  its  nursing  serv- 
ice further  in  the  direction  of  a  generalized  system,  without  at  present  im- 
posing further  duties  upon  the  staff  as  a  whole,  it  is  desirable  that  such  ex- 
tensions be  undertaken  in  one  district  only,  which  might  be  designated  the 
Extension  District.  One  of  the  present  Health  Center  Districts  might  be 
devoted  to  this  purpose. 

In  this  district  two  experiments  making  for  a  completely  generalized 
service  might  be  tried.  In  addition  to  the  present  activities  of  the  nursing 
staff,  the  following  services  might  be  undertaken: 

1 .  Prenatal  nursing  as  a  part  of  the  city -wide  plan. 

2.  School  nursing  in  the  parochial  schools. 

If  these  experiments  prove  successful  there  might  later  be  added; 

1.  General  medical  and  surgical  nursing  service. 

2.  Obstetrical  and  post-partum  nursing. 

In  order  to  provide  every  opportunity  to  make  such  an   extension  dis- 
trict successful,  it  should  have  the  following  favorable  factors: 

1.  A  district  of  approximately  50,000  people. 

2.  The  direction  of  a  well  trained  public  health  nurse  who  has  had 
experience  with  generalized  work,  including  visiting  nursing. 

3.  A  supervisory  staff  of  four  supervisors. 

4.  A  nursing  staff  of  18  nurses  (1  to  3,000  population). 

A  sub-committee  on'generalized  nursing  of  the  Central  Committee  might 
be  requested  by  the  Health  Commissioner  to  act  as  an  advisory  committee 
for  the  Extension  District  and  expected  to  exercise  close  oversight  of  its  con- 
duct and  results. 

RECOMMENDA  TWNS 

It  is  therefore  recommended  as  follows: 

ACTIVITIES 
/.   Communicable  Disease  Prevention: 

That  more  attention  be  given  to  protection  of  members  of  the  family  other  than  the 
patient,  to  arranging  for  adequate  nursing  of  the  patient,  and  to  instruction  regaiding 
prevention  of  sequelae. 

That  pneumonia,  measles,  whooping  cough  and  typhoid  cases  be  reported  to  the  Visiting 
Nurse  Association,  which  will  seek  permission  of  the  private  doctor  to  give  nuning. 


770  Hospital  and  Health  Survey 


2.  Tuberculosis  Work: 

That  this  service  be  continued  and  greatly  increased,  especially  in  the  field  of  home 
visiting  for  instruction  and  nursing  purposes,  and  in  an  effort  to  discover  new  cases.  All 
tuberculosis  patients  should  te  visited  at  least  once  a  month  and  those  in  need  of  care 
much  more  frequently.  Much  more  effort  must  be  given  to  having  the  family  and  those 
exposed  examined. 

3.  Child  Hygiene: 

That  this  service  be  continued  and  amplified.  Much  more  home  visiting  is  impera- 
tive for  careful  instruction  in  infant  and  child  care  and  for  nursing  care.  That  a  standard 
routine  be  adopted  and  mechanical  methods  devised  to  check  it  up.  All  babies  should  be 
visited  at  least  once  a  month  and  sick  babies  daily. 

4.  Supervision  of  Midwives: 

That  this  work  be  increased;  visits  be  made  more  frequently;  time  be  provided  for 
hunting  illegal  practitioners,  for  demonstration  and  for  inspection  of  technique  and  de- 
livery. 

5.  Prevention  of  Blindness: 

That  the  present  routine  be  continued,  but  it  should  be  made  certain  that  the  care 
given  is  adequate  in  frequency  and  quality. 

6.  Supervision  of  Boarding  Homes  for  Babies: 

That  a  definite  routine  of  visits  and  procedures  be  established,  extending  to  these 
babies  constant  oversight  in  all  matters  of  health  and  general  care,  as  well  as  feeding. 

7.  Parochial  School  Nursing: 

That  the  present  entirely  inadequate  and  nearly  futile  effort  of  providing  service  for 
all  parochial  schools  be  discontinued.  That  all  parochial  school  nursing  be  concentrated 
in  the  proposed  Extension  District,  whc;re  an  intensive  piece  of  work  may  be  done. 

8.  Prenatal  Nursing: 

That  this  service  be  restricted  to  the  proposed  Extension  District,  as  a  part  of  the 
city -wide  maternity  system. 

9.  Extension  District: 

That  one  of  the  present  Health  Center  districts  be  set  apart  as  an  Extension  District 
for  the  purpose  of  initiating  new  projects  or  methods  before  undertaking  them  on  a  city- 
wide  basis,  in  accordance  with  the  detailed  suggestions  made  above. 

ADMINISTRATION 
1.   Organization: 

(a)  That  all  nursing  service  now  carried  on  or  to  be  carried  on  by  the  Division  of 
Health  be  under  the  direction  of  a  Director  of  Nurses,  who  should  be  immediately  respon- 
sible to  the  Commissioner  of  Health. 


N-U:E[£'ING  771 

(b)  That  the  nursing  service  for  the  Bureaus,  whose  work  requires  the  services  of 
nursing  (such  as  the  Bureau  of  Communicable  Disease,  the  Bureau  of  Child  Hygiene, 
and  the  Bureau  of  Tuberculosis)  be  performed  by  the  general  staff  of  nurses,  and  that  the 
proper  relations  shall  be  maintained  through  consultation  by  the  Director  of  Nursing, 
and  the  Directors  of  the  three  mentioned  bureaus,  all  policies  and  decisions  being  subject 
to  the  approval  of  the  Commissioner  of  Health. 

2.  Headquarters  Staff: 

(a)  That  the  positions  of  Director  and  Assistant  Director  be  continued  as  at  present. 

(b)  That  the  present  plan  of  special  supervision  be  discontinued  and  reorganized  as 
follows : 

That  four  assistant  supervisors  be  appointed,  each  to  have  charge  of 
the  general  oversight  of  certain  activities,  as  follows: 

1.  Baby  and  child  hygiene. 

2.  Communicable  disease. 

3.  Tuberculosis. 

4.  Midwifery,  boarding  homes,  eye  work. 

The  fourth  assistant  supervisor  to  have  an  assistant. 

(c)  That  these  supervisors  should  have  two  functions,  acting  as  special  consultants 
in  their  own  field,  and  as  instructors  in  their  special  services.  These  supervisors  should 
work  out  and  conduct  a  scheme  of  continuous  education  for  the  staff.  They  should  be 
responsible  for  the  instruction  of  new  nurses  in  the  routine  policies  and  procedures  of  the 
work  and  in  the  special  technique  and  practices  of  each  special  service.  They  should  also 
be  responsible  for  classes,  consultations  and  conferences  for  the  whole  staff. 

In  their  capacity  as  special  consultants  they  should  be  responsible  for  the  study  and 
analysis  of  the  nursing  work  accomplished,  both  as  to  quality  and  quantity,  and  the  de- 
velopment of  this  work  in  their  own  special  services.  They  should  make  studies  in>  co- 
operation with  the  directors  of  the  various  bureaus  of  the  Division  of  Health,  and  should 
act  as  liaison  officers  between  these  bureaus  and  the  nursing  service.  They  should  act  as 
a  connecting  link  between  the  Nursing  Service  and  the  special  outside  institutions  related 
to  their  work. 

(d)  That  there  should  be  an  office  manager  responsible  for  all  the  business  details 
of  the  office,  and  for  all  the  records.  This  position  should  be  sufficiently  well  paid  to 
make  possible  the  employment  of  a  thoroughly  competent  woman. 

(e)  That  the  Director  of  Nursing  should  have  a  private  office. 

3.  Records: 

That  the  record  system  be  simplified;  that  a  record  expert  or  the  statistician  of  the 
Division  of  Health  be  employed  to  set  up  a  simple,  practical  and  effective  record  system 
and  that  the  statistical  work  be  done  by  the  office  of  the  statistician  of  the  Division  of 
Health  rather  than  by  the  nurses. 

The  record  system  for  the  Health  Centers  and  Headquarters  should  be  uniform,  and 
the  office  manager  should  be  held  responsible  for  it.     In  order  to  secure  continuity  and 


772  Hospital  and  Health  Survey 

high  grade  service  there  should  be  assurance  oe  promotion  and  increase  in  salary  for  all 
the  clerical  staff,  based  on  merit. 

4.  Health  Centers: 

(a)  That  there  should  be  a  district  supervisoi,  who  should  be  responsible  for  the 
administration  of  the  Health  Center,  but  whose  principal  duty  should  be  the  supervision 
of  the  staff  nurses  and  their  work  in  the  homes.  Fully  two-thirds  of  her  time  should  be 
given  to  field  supervision.  She  should  not  be  subordinate  to  but  chief  over  the  clinic 
nurse  and  the  office  manager,  suggested  below. 

(b)  That  there  should  be  a  clinic  or  dispensary  nurse  whose  full  time  should  be  de- 
voted to  the  Health  Center,  for  the  purpose  of  running  the  clinics  and  talking  with  patients 
who  come  out  of  clinic  hours.  She  should  have  no  responsibility  for  home  case  work  or 
for  field  work. 

(c)  That  there  should  be  an  office  manager  (not  a  nurse  but  a  competent  business 
woman),  who  should  have  charge  of  the  business  management  of  the  center  and  of  all  the 
mechanical  and  record  work,  and  receiving  calls  and  relaying  such  of  them  as  are  emergent, 
to  the  nurses  in  the  field.  There  should  be  a  uniform  system  for  office  management  and 
record  work  in  all  the  centers.  Salaries  should  be  paid  in  these  positions  high  enough  to 
.nsure  a  thoroughly  reliable,  intelligent  and  businesslike  personnel. 

(d)  That  the  practice  of  having  two  or  three  nurses  in  attendance  at  clinics  be  dis- 
continued; that  the  clinics  be  conducted  by  the  dispensary  nurse  with  the  possible  assist- 
ance of  one  staff  nurse;  that  if  more  assistance  is  required,  it  be  provided  by  a  clerical  worker 
and  not  by  a  nurse. 

(e)  That  a  routine  of  field  supervision  be  established,  and  that  the  field  supervisors 
render  to  the  Director  a  weekly  record  of  their  work. 

(f)  That  a  separate  room  be  provided  in  the  Health  Centers  for  the  field  superviso 
and  her  field  nurses. 

(g)  That  districts  be  greatly  reduced  in  size,  possibly  cut  in  half. 

5.  Field  Staff: 

(a)  That  the  staff  should  be  increased  until  no  nurse  carries  more  than  125  patients, 
preferably  100.     This  will  mean  largely  increasing  the  present  staff. 

(b)  That  the  staff  nurses  consult  with  the  field  supervisor  daily  concerning  their  case 
work  and  that  she  in  turn  take  up  any  special  case  problems  with  the  special  supervisors 
at  Headquarters. 

(c)  That  an  efficiency  report  be  prepared  by  the  field  supervisors  monthly  for 
each  nurse,  to  be  submitted  to  the  Director  and  kept  on  file. 

(d)  That  each  staff  nurse  prepare  a  monthly  statirtical  report  of  her  work. 

(e)  That  new  nurses  spend  the  first  two  or  three  days  of  their  service  in  the  main 
office  to  receive  instructions  from  the  special  supervisors  in  the  routine,  the  records  and  the 
general  practices  of  the  work. 


Nursing  773 

(f)  That  new  nurses  be  taken  out  by  the  field  supervisor  for  at  least  two  or  three 
days  before  they  are  allowed  to  go  alone,  and  that  they  be  then  visited  at  frequent 
intervals  by  the  field  supervisor  (once  a  week  for  a  month)  while  at  work  in  their  district. 

(g)  That  new  nurses  attend  weekly  classes  at  the  City  Hall,  to  be  conducted  by  the 
special  supervisors,  to  be  trained  in  the  technique  and  methods  of  work  in  the  special  fields. 

(h)  That  the  weekly  conference  now  being  held  for  the  whole  staff  at  the  City  Hall 
be  continued,  and  be  included  in  the  scheme  of  education  worked  out  by  the  special  super- 
visors. 

6.  Salaries: 

That  the  salaries  of  the  staff  nurses,  the  field  supervisors  and  the  special  super- 
visors, be  increased  to  meet  the  schedule  recently  recommended  by  the  Central  Nursing 
Committee. 

7.  Uniform: 

That  a  wash  uniform  be  adopted  and  worn  by  all  members  of  the  staff  (except  the 
Headquarters  Staff,  if  so  desired). 


Tne  Visiting  Nurse  Association  of  Cleveland 
Scope  of  the  Work 

THE  Visiting  Nurse  Association  of  Cleveland  undertakes  to  extend  home 
nursing  care,  except  in  communicable  disease,  to  anyone  in  the  city  not 
cared  for  by  any  other  public  health  nursing  agency.  This  service  is 
given  free  to  those  unable  to  pay  for  it;  part  pay  is  charged  to  those  unable 
to  pay  the  regular  fee;  all  others  pay  the  full  fee.  The  pay  sjrv'cs  is  not 
restricted,  but  may  be  used  by  anyone  except  that  it  cannot  be  obtained  at 
a  regular  fixed  hour,  nor  extending  over  one-half  day,  nor  for  cases  in  which 
only  attendance  is  wanted  and  no  nursing  care  for  illness  is  needed.  Visit- 
ing nursing  is  also  provided  for  policy  holders  of  the  Metropolitan  Life  In- 
surance Company,  for  which  the  company  pays  the  Association  at  the  rate 
of  sixty  cents  (60  cents*)  per  visit. 

Nursing  care  in  tuberculosis  is  given  only  to  those  patients  able  to  pay 
75  cents  or  more  per  visit;  care  is  given  in  diseases  of  babies  under  three 
years,  attended  by  private  doctors,  but  not  to  babies  attending  the  clinics 
of  the  Division  of  Health;  and  care  is  not  given  in  illness  among  industrial 
workers  who  are  provided  with  home  nursing  service  by  their  employers. 

With  these  exceptions  the  Association  undertakes  to  care  for  patients  of 
all  ages  and  patients  with  all  types  of  disease,  acute  and  chronic,  medical, 
surgical  and  obstetrical,  including  also  the  making  and  teaching  of  milk 
modifications  for  infants  under  the  care  of  private  doctors. 

Like  all  visiting  nurse  associations  of  equal  grade,  the  Cleveland  Associa- 
tion has  placed  chief  emphasis  upon  the  primary  need  of  caring  for  the  poor 

*  Charge  has  now  been  changed  to  $1.00  as  recommended  by  the  Survey. 


774  Hospital  and  Health  Survey 

who  cannot  pay  for  nursing  service.     Second,  is  felt  the  need  of  caring  for 
persons  of  small  means  who  may  be  able  to  pay  a  very  small  fee. 

For  persons  of  moderate  income  a  pay  service  at  cost  has  been  recently 
introduced  and  should  be  widely  extended.  The  extension  of  pay  service 
is  not  alien  to  the  policies  and  purposes  of  any  well  organized  visiting  nurse 
association,  but  is  a  natural  and  logical  development  of  its  work.  Such  a 
well  organ iaed  hourly  service,  at  a  moderate  price,  under  centralized 
management  is  not  unlikely  in  the  future  to  solve  the  problem  of  the  de- 
creasing number  and  increasing  cost  of  private  duty  nurses. 

One  of  the  striking  developments  in  paid  service,  which  the  Cleveland 
Association,  like  a  few  other  leading  nursing  organizations,  has  recently  taken 
up,  is  a  paid  day  and  night  service  during  delivery.  This  work  fills  a  need 
than  which  none  is  more  important,  but  with  which  for  lack  of  the  necessary 
personnel  and  funds,  visiting  nurse  associations  have  in  the  past  not  attempted 
to  grapple. 

The  value  of  teaching  family  hygiene  and  giving  attention  to  the  health 
and  hygienic  habits  of  the  whole  family  is  recognized  by  the  Association, 
but  is  not  sufficiently  emphasized  as  a  definite  function  of  the  nurse. 

The  Present  Equipment 

In  order  to  perform  this  work  a  staff  is  maintained  consisting  of  a  super- 
intendent of  nurses,  an  assistant  superintendent,  three  supervisors,  and  at 
present  21  regular  staff  nurses  and  six  substitutes,  and  a  clerical  staff  con- 
sisting of  one  office  secretary  and  one  clerk  at  central  office  and  one  stenog- 
rapher at  each  sub-station.  There  are  a  central  office  and  three  district 
offices,  all  of  which  are  ample  in  size  and  equipment  for  their  functions. 

Analysis  of  Activities 

Study  of  the  work  performed  by  the  Visiting  Nurse  Association  proves 
it  to  be  of  highest  grade  so  far  as  it  goes,  but  that  it  does  not  go  far  enough. 
The  spirit  manifested  by  the  whole  organization  is  lofty,  and  the  work  is 
thorough,  painstaking  and  kindly. 

This  Association  has  been  of  great  value  in  demonstrating  many  activi- 
ties to  the  municipality,  such  as  the  care  of  tuberculosis,  industrial  nursing, 
and,  together  with  the  Babies'  Dispensary,  work  for  babies  both  sick  and  well, 
etc.  By  turning  over  these  successive  activities  to  municipal  and  private 
agencies,  the  present  scoDe  of  the  work  appears  to  be  narrowing  and  to  lack 
extension  into  the  new  fields  of  services  waiting  to  be  developed. 

The  Board  of  Trustees  of  the  Visiting  Nurse  Association  has  never  lacked 
vision  for  new  opportunities  of  service.  It  will  doubtless  continue  its  policy 
of  extending  into  new  fields  as  occasion  offers. 

Care  of  the  Sick 

The  care  of  medical  and  surgical  patients  occupies  the  greatest  part  of 
the  nurses'  time.     Approximately  four-fifths  of  the  patients  are  medical  or 


Nursing  775 

surgical  cases,  only  a  very  small  percentage  (less  than  1%)  of  whom  are 
chronics.  The  kinds  of  illness  cared  for  are  many,  but  include  very  few 
cases  of  tuberculosis  or  other  communicable  diseases  or  intestinal  diseases  of 
infancy.  Between  October,  1918,  and  October,  1919,  51  tuberculosis  patients 
and  16  intestinal  cases  among  babies  were  treated.  Yet  the  records  of  the 
Division  of  Health  show  that  the  second  highest  cause  of  death  in  the  city 
of  Cleveland  in  1917  was  tuberculosis,  and  the  third,  diarrhoea  and  enteritis 
among  children  under  two  years  of  age. 

While  it  is  true  that  the  Division  of  Health  provides  for  the  care  of  all 
contagious  diseases  and  for  tuberculosis  patients  not  able  to  pay  75  cents  a 
visit,  and  of  sick  babies  whose  parents  are  unable  to  pay  75  cents,  it  never- 
theless is  surprising  that  so  few  tuberculous  patients  over  the  75  cent  limit 
were  found  in  need  of  nursing  care,  and  so  few  sick  babies  outside  the  scope 
of  the  municipal  staff.  While  the  city  record  shows  only  165  cases  of  typhoid 
during  the  year,  a  negligible  number  of  these,  only  five,  are  on  the  visiting- 
nurse  list. 

Moreover,  few  post-operative  cases  discharged  from  hospitals  before  com- 
plete recovery  are  under  visiting  nurse  care.  Many  hospitals  dismiss  sur- 
gical patients  as  soon  as  they  have  recovered  from  the  operation  itself,  who 
still  require  dressings  of  the  wound  for  weeks  and  possibly  for  months.  For 
patients  of  little  or  no  income  these  dressings  should  be  done  without  cost. 
Visiting  nurse  service  would  seem  to  be  the  solution.  Frequently,  also, 
private  doctors  are  glad  to  turn  over  such  dressings  to  the  visiting  nurse, 
doing  the  dressings  themselves  only  often  enough  to  keep  track  of  the  prog- 
ress of  healing.  Apparently,  little  such  service  is  rendered  by  the  Cleveland 
Association,  although  there  is  presumably  considerable  need  for  it.  Indeed 
the  Association  should  be  called  on  for  a  wider  service  of  the  kind. 

It  is  desirable  that  the  hospitals  should  send  the  regular  clinic  agents  to 
call  on  patients  merely  to  secure  their  return,  or  where  there  are  special  medi- 
cal or  social  conditions  which  the  hospital  has  studied  and  with  which  it  is 
in  touch.  But  all  patients  leaving  the  hospital  who  need  medical  or  surgical 
care  are  appropriate  patients  for  the  Visiting  Nurse  Association  and  an  effort 
should  be  made  to  have  the  hospitals  refer  them  to  the  Association. 

Observation  of  a  limited  number  of  home  visits  showed  the  quality  and 
character  of  nursing  care  to  be  excellent,  being  careful  and  thorough,  and 
done  with  much  gentleness,  where  the  work  of  the  nurses  in  their  districts 
was  observed  by  the  investigator.  Marked  kindness,  sympathy  and  interest 
was  shown  by  the  nurses  in  most  cases.  It  was  apparent,  however,  that  the 
actual  nursing  care  given  was  of  first  importance  in  the  eyes  of  the  nurses; 
and  that  they  failed  to  consider  the  health  of  the  whole  family  as  part  of  their 
responsibilities  and  did  not  take  sufficient  advantage  of  opportunities  to 
teach  prevention  of  illness,  or  home  and  family  hygiene. 

The  records  of  the  Association,  however,  show  that  a  substantial  amount 
of  attention  was  devoted  to  social  diagnosis  and  treatment,  since  practically 
25  per  cent  of  the  patients  cared  for  between  October,  1918,  and  October, 
1919,  were  referred  to  hospitals,  dispensaries,  or  other  health  or  social  agen- 
cies. 


776  Hospital  and  Health  Survey 

While  undoubtedly  the  giving  of  nursing  care  is  the  prime  function  of  a 
visiting  nurse  association,  it  seems  clear  that  more  teaching  could  be  done 
by  the  Cleveland  staff  without  lessening  the  quality  or  quantity  of  nursing 
care. 

Many  opportunities  also  present  themselves  to  secure  or  advise  treat- 
ment— medical,  surgical,  dental,  optical  or  hygienic — for  members  of  the 
family  not  coming  within  the  range  of  the  school,  municipal  or  industrial 
nurses.  While  the  statistics  in  Cleveland  do  not  show  the  amount  of  such 
work  done,  none  of  the  visiting  nurses  who  were  accompanied  in  the  districts 
seemed  to  be  taking  advantage  of  these  opportunities  as  vigorously  as  they 
might. 

In  the  opinion  of  the  Superintendent  of  the  Association  the  sick  among 
the  poor  are  receiving  adequate  care  and  are  being  brought  to  the  attention 
of  the  Association,  through  its  cordial  relations  with  other  social  remedial 
agencies  and  their  frequent  calls.  There  are,  however,  no  statistics  to  show 
the  number  of  patients  so  referred.  The  Superintendent  thought  that  the 
pay  service  had  not  reached  its  maximum  usefulness,  and  that  a  decided  ex- 
tension of  this  service  was  needed,  and  would  be  of  benefit  to  and  well  re- 
ceived by  those  of  small  and  moderate  income. 

Prenatal  Nursing 

It  was  found  that  prenatal  care  was  being  extended  to  patients  under  the 
care  of  private  physicians  and  to  patients  expecting  to  go  to  the  hospital  for 
confinement  or  to  have  a  midwife.  It  was  not  given  to  patients  under  the 
care  of  an  out-patient  maternity  service.  It  was  stated  that,  although  they 
engaged  the  doctor  some  time  ahead,  very  few  of  the  pregnant  patients 
carried  by  the  visiting  nurses  had  medical  oversight  until  the  time  of  con- 
finement.^ Hence  the  prenatal  instructions  given  to  those  patients  by  the 
nurses,  with  the  doctors'  consent,  are  of  special  value  as  safeguards. 

With  the  wide  possibilities  of  benefit  inherent  in  prenatal  nursing  both 
for  the  individual  mother  and  for  the  community,  this  nursing  service  should 
go  further  than  it  now  does.  Visits  are  a  month  or  more  apart,  instead  of 
every  ten  days  or  two  weeks  as  they  should  be  for  the  best  results;  no  urin- 
alysis is  made  or  blood  pressure  taken,  and  instruction  might  be  somewhat 
more  thorough.  The  reason  given  was  that  the  nurses  did  not  have  time  to 
make  frequent  calls  of  sufficient  length  upon  these  patients.  They  would 
be  glad  to  enlarge  this  service  and  could  do  so  with  great  advantage  if  the 
staff  were  increased  sufficiently. 

Maternity  Service 

The  post-natal  care  given  by  the  regular  staff  nurses  was  excellent.  The 
work  of  the  special  obstetrical  nurses  was  not  observed,  but  judging  from  the 
high  quality  of  the  work  of  the  rest  of  the  staff,  it  is  presumed  that  this  was 
well  done  also.  This  service  is  provided  at  any  time  to  any  home  patient 
under  the  care  of  a  private  physician  and  able  to  pay  the  fee  of  $5.00*  It  is 
not  provided  to  patients  unable  to  pay  this  fee,  since  such  patients  are  not 

•  This  fee  has  been  changed  to  $7.00  since  the  investigation  was  made. 


Nursing  777 

usually  under  the  care  of  a  private  physician,  but  have  hospital  or  out-patient 
maternity  care,  which  provides  nursing  service.  The  maternity  service  of 
the  Visiting  Nurse  Association,  though  still  on  a  small  scale  (234  confinements 
in  1919),  is  steadily  growing.  It  should  be  increased  as  rapidly  as  the  staff 
can  be  increased  to  care  for  it. 

Factory  Service 

Two  factories  are  in  affiliation  with  the  Visiting  Nurse  Association  through 
contract,  one  being  supplied  with  two  nurses  and  the  other  with  one  through 
the  Visiting  Nurse  Association.  These  nurses  were  former  members  of  the 
visiting  nurse  staff  and  are  still  supervised  by  its  superintendent  and  her 
assistant.  They  send  to  the  Association  a  monthly  statistical  report  and 
attend  the  staff  meetings.  During  the  factory  nurses'  illness  or  vacation, 
the  Association  supplies  a  substitute.  The  factories  pay  the  Association  for 
this  service,  including  salary,  equipment  and  carfare,  and  the  Association 
pays  the  nurses,  who  wear  its  uniform.  In  the  past  such  an  arrangement 
was  maintained  with  six  factories,  but  four  have  discontinued  it.  It  is 
highly  desirable  that  the  Central  Nursing  Committee  work  out  a  plan  for 
some  agency  to  assume  this  activity.  Supervision  of  the  104  industrial 
nurses  in  Cleveland  is  urgently  needed.  (For  further  details  of  nurses  in 
industry  see  Part  VII.) 

Out-Patient  Maternity  Affiliation 

Up  to  January,  1920,  both  the  out-patient  maternity  service  of  Western 
Reserve  and  of  St.  Luke's  were  in  affiliation  with  the  Visiting  Nurse  Asso- 
ciation. Formerly  this  meant  that  the  Visiting  Nurse  Association  selected 
the  nurse,  but  recently  the  hospitals  have  selected  the  nurses,  and  they  have 
had  their  selection  "regularized"  by  passing  their  credentials  through  the 
Central  Committee  and  the  Visiting  Nurse  Association.  This  affiliation  has 
come  to  be  only  a  form  since  the  Association  does  not  select  or  supervise  the 
nurses  or  have  any  authority  over  their  work.  All  that  remains  is  that  the 
nurses'  salaries  are  paid  through  the  Association.  There  appear  to  be  no 
advantages  in  this  arrangement,  and  it  is  clearly  a  disadvantage  to  the  Visit- 
ing Nurse  Association  to  be  responsible  for  a  piece  of  work  over  which  it  has 
no  authority.  January  1st  this  affiliation  was  discontinued  with  St.  Luke's, 
but  continued  with  Western  Reserve. 

The  Medical  College  had  a  gift  some  years  ago  for  a  memorial  nurse,  the 
"Powell  Nurse,"  for  its  out-patient  maternity  service.  The  College  believes 
there  was  a  stipulation  that  the  nurse  should  come  through  the  Visiting 
Nurse  Association,  and  is  therefore  unwilling  to  discontinue  this  perfunctory 
affiliation  for  fear  of  losing  the  right  to  this  gift.  It  would  seem  that  such 
arrangements  should  be  abandoned  in  favor  of  a  city-wide  single  prenatal 
service,  recommendations  for  which  are  given  elsewhere. 

Pilgrim  Church  Service 

Pilgrim  Church  pays  $500.00  a  year  towards  the  salary  of  one  nurse  to 
care  for  the  people  in  the  neighborhood  of  the  church.  The  church  endeavors 
to  serve  a  non-sectarian  group.     The  nurse  has  her  office  in  the  churchjmild- 


778  .  Hospital  and  Health  Survey 

ing,  at  the  request  of  the  church,  in  order  to  make  a  place  where  the  neigh- 
bors can  be  cared  for.  She  does  many  dressings  in  her  office,  and  also  in- 
spects and  watches  over  the  church  kindergarten.  The  church  has  marked 
out-  the  area  in  the  city  which  it  wants  her  to  serve.  This  area  is  not  an 
appropriate  one  in  relation  to  the  rest  of  the  West  Side  district.  Nurses 
going  into  one  district  must  frequently  cross  this  district.  The  western  sec- 
tion of  it  is  more  accessible  to  one  of  the  other  districts. 

The  nurse  does  not  report  to  the  West  Side  office  or  keep  her  records  there, 
the  latter  being  kept  in  the  church  office.*  The  supervisor  of  the  West  Side 
district,  therefore,  must  come  to  the  nurse's  office  in  order  to  see  her  or  to  go 
over  her  records.  The  result  of  this  arrangement  is  that  the  nurse  works 
almost  alone  and  receives  very  little  supervision  and  assistance. 

This  arrangement  appears  to  be  inadvisable,  both  from  the  point  of  view 
of  policy  and  of  administration.  As  a  matter  of  policy,  it  would  be  awkward, 
if  contributions  were  to  be  received  from  other  churches,  to  permit  them  to 
determine  the  location  of  the  nurse's  district,  and  to  have  her  office  in  the 
church.  This  would  result  in  confusion  and  disorganization  of  the  present 
well  planned  system  of  the  Visiting  Nurse  Association.  The  precedent, 
therefore,  seems  to  be  a  bad  one.  From  an  administrative  point  of  view,  the 
result  is  the  undesirable  isolation  of  one  of  the  members  of  the  staff,  cutting 
her  off  from  intercourse  with  other  members  and  from  the  assistance  and  over- 
sight of  her  supervisor;  also  the  necessity  of  maintaining  district  boundaries 
which  are  exceedingly  disadvantageous  to  the  management  of  the  work  in 
the  West  Side  district. 

Service  Outside  of  the  City 

.  Lakewood  has  its  own  Visiting  Nurse  Association,  which  is  affiliated  with 
the  Association  in  Cleveland.  It  has  a  separate  Board  of  Trustees,  who  raise 
funds,  determine  policies  and  administer  the  work.  The  nurses,  however, 
are  supplied  by  the  Cleveland  Association,  which  also  supplies  substitutes 
when  needed.  Salaries  are  paid  through  the  Cleveland  Association.  These 
Lakewood  nurses  attend  the  staff  meetings  of  the  Cleveland  Association, 
and  are  supervised  by  the  superintendent  of  the  Association  or  her  assistant. 
They  wear  the  Cleveland  uniform  and  send  a  monthly  report  to  the  Cleveland 
Association. 

;  Bratenahl  Village,  a  well-to-do  residential  section,  pays  the  Association 
$250.00  a  year  to  have  a  nurse  call  twice  a  week  at  the  school  to  inspect  the 
children.'  There  is  also  a  school  doctor,  who  attends  occasionally.  The 
nurse  does  little  home  visiting. 

Analysis  of  Administration 

The  administration  of  the  activities  of  the  Visiting  Nurse  Association 
seems  to  be  well  planned,  systematized  and  carried  out.  The  main  office 
and  sub-stations  are  managed  in  a  smooth,  businesslike  way  and  for  the  most 

*  Since  the  recommendations  of  the  Survey  were  received  the  records  have  been  removed  from  the 
Pilgrim  Church  and  the  Pilgrim  nurse  reports  three  times  a  week  to  the  West  Side  Station. 


N  fj  r  s  i  x  G  779 

part  the:  record  systems  seem  to  be  adequate,  fairly  simple  and  kept  up-to- 
date.  The  amount  of  clerical  work  required  of  the  nurses  has  been  reduced 
to  a  minimum. 

No  record  is  kept  of  the  source  of  calls,  making  it  impossible  to  analyse 
the  frequency  and  amount  of  the  use  made  of  the  Association  by  other  agen- 
cies. An  annual  analysis  of  the  sources  from  which  calls  come  would  be  illumi- 
nating. It  frequently  shows  that  certain  agencies  are  not  calling  upon  the 
Association  at  all,  or  not  as  frequently  as  they  might,  or  that  agencies  with 
whom  close  relations  were  supposed  to  exist  have  in  reality  made  few  calls 
upon  the  Association.  It  gives  definite  evidence  of  the  number  of  dismissed 
patients  turned  over  to  the  Visiting  Nurses  by  the  hospitals.  It  shows  to 
what  extent  the  doctors  are  making  use  of  the  nurses.  All  the  members  of 
the  Visiting  Nurse  staff  interviewed  indicated  that  the  doctors  were  giving 
the  Association  excellent  cooperation,  but  there  were  no  statistics  to  prove 
this  fact.  A  tabulation  of  the  sources  of  calls  would  give  all  this  information, 
and  afford  a  definite  basis  on  which  to  determine  where  the  service  could  be 
built  up. 

There  is  a  cheerful,  dignified  spirit  among  the  members  of  the  staff, 
both  in  the  stations  and  in  the  districts.  Devotion  to  the  work  seems  to  be 
genuine  and  whole  hearted,  and  it  is  quite  evident  that  the  officers  and  staff 
of  the  Association  are  working  constantly  to  insure  a  dependable  quality  of 
service.  The  harmony  that  exists  among  the  supervisors  and  their  constant 
oversight  of  the  work  in  the  field  tend  to  stabilize  the  service  and  to  insure  to 
the  patients  skilled  and  carefully  planned  services.  The  supervisors  make 
every  effort  to  insure  the  best  of  care  to  the  patients  without  overworking 
the  nurses  While  only  four  nurses  were  accompanied  in  the  districts,  one 
of  whom  did  not  come  up  to  standards,  the  work  observed  bore  the  marks  of 
consistency,  honesty  and  well  grounded  preparation. 

Two  or  three  factors,  however,  tend  to  diminish  initiative  and  ability  to 
plan  and  manage  on  the  part  of  the  staff  nurses.  These  factors  are  the  fol- 
lowing:* 

(a)  In  two  districts  the  supervisors  allow  the  nurses  too  little  planning 
of  the  day's  work.  The  nurses  make  out  a  list  of  their  calls,  and  the  super- 
visor then  changes  the  arrangement  of  them  as  she  sees  fit,  or  decides  which 
patients  are  to  be  seen  and  which  are  not.  This  takes  away  from  the  staff 
nurse  the  necessity  of  planning  her  own  work  and  of  managing  and  perform- 
ing it  in  a  way  to  bring  about  the  best  results.  It  lessens  her  sense  of  respon- 
sibility and  makes  her  very  dependent  upon  her  supervisors. 

(b)  The  unit  of  the  organization  so  far  as  records  are  concerned  is  the 
supervisor's  district  and  not  the  staff  nurse's  district.  The  districts  occupied 
by  the  staff  have  no  name,  letter,  or  distinguishing  mark  and  no  identity. 
The  list  of  patients  and  the  statistical  report  of  the  work  is  made  out  for 
the  whole  district  covered  by  the  supervisor  and  not  for  the  smaller  districts 
in  which  the  nurses  themselves  are  working.     This  means  that  there  is  no 

*  Since  the  Survey  recommendations  were  received  the  following  changes  have  been  made.  Every 
nurse  now  has  her  own  district,  keeps  her  own  day-book,  makes  out  her  own  monthly  statistical  report. 


780  Hospital  and  Health  Survey 

way  of  picturing  the  work  in  each  nurse's  district  as  a  single  piece  of  work; 
no  method  of  measuring  the  work  performed  by  individual  nurses,  conse- 
quently no  basis  of  comparison  and  no  basis  for  pride  in  accomplishment. 
This  does  not  tend  to  build  up  individual  initiative,  or  the  spirit  of  competi- 
tion with  the  work  of  other  members  of  the  staff.  No  use  is  made  of  the 
census  tracts  of  the  city  in  outlying  districts,  either  for  the  individual  nurse 
or  fcr  the  supervisor's  district.  These  fundamental  districts  as  arranged 
for  useTsy  the  census  should  be  used  as  units  or  by  multiples  for  the  Visiting 
Nurse  Association  administration  as  for  the  district  subdivisions  of  every 
other  private  and  public  health  agency. 

(c)  In  two  districts  many  of  the  nurses  make  a  practice  of  returning  to 
the  station  three  times  a  day.*  This  is  a  waste  of  time,  and  again  weakens 
the  nurse's  sense  of  responsibility  for  her  work.  The  tendency  is  for  her  to 
go  to  her  supervisor  constantly  for  advice  rather  than  to  think  out  her  prob- 
lems herself. 

While  there  is  thus  no  lack  of  supervision  and  in  some  cases  too  much 
supervision  in  the  administration  of  the  work,  there  might  to  advantage  be 
even  more  supervision  than  there  is  in  the  home  visiting.  A  study  of  the 
supervisors'  record  for  two  months  showed  that  during  one  month  super- 
visors went  into  the  districts  with  the  staff  nurses  33  times,  and  the  second 
month  34  times,  visiting  in  the  first  month  64  families,  and  in  the  second  114; 
yet  in  one  month  four  nurses  were  not  ever  accompanied  by  the  supervisor, 
and  in  the  other  month  six  nurses  were  unaccompanied. 

According  to  this  record  the  supervisors  spent  an  average  of  about  one- 
third  of  their  time  in  the  field,  but  not  more  than  half  of  this  was  spent 
in  accompanying  the  staff  nurses.  The  supervisors  appear  to  make  visits 
alone  in  the  district.  This  is  not  desirable  practice,  as  it  means  that  the  nurses 
are  deprived  of  the  supervisors'  guidance  in  such  cases  and  that  the  super- 
visors are  handling  alone  the  most  difficult  situations,  instead  of  using  them 
as  teaching  opportunities. 

A  good  feature  of  the  work  is  that  the  supervisors  regularly  attend  the 
case  conferences  held  by  the  Associated  Charities.  It  is  desirable  that  the 
staff  nurses  who  occasionally  attend  these  conferences,  should  also  do  so 
regularly. 

The  nurses  average  seven  and  a  half  calls  a  day.  If  the  nurses  did  not 
return  to  the  office  so  often  more  work  might  be  accomplished  without  inter- 
fering with  its  finish.  With  an  enlarged  staff  and  a  saving  of  the  nurses' 
time  in  going  back  and  forth,  especially  in  the  outlying  districts,  the  activi- 
ties of  the  Association  might  be  doubled  and  many  more  persons  get  the  bene- 
fit of  the  fine  services  offered. 

Experience  in  many  communities  has  proved  that  until  the  city  is  able  to 
take  over  these  nursing  services  in  full,  private  organizations  must  perform 
this  function  of  helping  save  life  and  restore  health.  The  overwhelming 
majority  of  sick  persons  must  be  cared  for  in  their  homes;   a  very  small  pro- 

*  The  nurses  now  are  required  to  go  to  the  station  but  once  a  day. 


Nursing  781 

portion  are  cared  for  in  hospitals.     The  visiting  nurses  must  be  supported., 
since  to  them  the  community  must  look  for  this  home  nursing  care. 

RECOMMENDA  TIONS 

It  is  recommended: 

ACTIVITIES 

(a)  That  care  of  the  sick  be  extended  to  a  larger  proportion  of  the  population,  espe  - 
cially  to  persons  of  small  and  moderate  income,  through  vigorous  advertising  and  other 
campaign  methods.  The  work  may  well  be  extended  district  by  district  as  the  staff  is 
increased,  rather  than  to  undertake  it  at  once  for  the  whole  city  with  inadequate  staff. 

The  full  fee  for  the  pay  service  should  be  increased  to  $1.00  to  cover  the  cost  of  a 
visit.  It  is  believed  that  this  service  will  never  be  attractive  to  persons  above  the  poverty 
line,  unless  they  are  able  to  pay  its  full  cost. 

(b)  That  the  affiliation  now  existing  with  the  Maternity  Hospital  be  discontinued. 

1  That   responsibility  be   assumed   for   a   city-wide   prenatal   and   ma- 
ternity nursing  service,  elsewhere  recommended  in  detail. 

2  That  the  present  paid  day  and  night  maternity  service  be  expanded. 

(c)  That  greater  efforts  be  made  to  reach  sick  babies  and  tuberculous  patients  through 
the  pay  service. 

(d)  1  That  arrangements  be  made  with  the  several  hospitals  to  refer  to  the 
Association  all  patients  leaving  the  hospital  who  are  in  need  of  nursing  care 
either  surgical  or  medical,  and  also  all  dispensary  cases  needing  nursing 
care  and  unable  to  return  to  the  clinic. 

2    That  the  doctors  who  seem  to  have   the  majority    of   such   cases    be 
offered  the  services  of  the  visiting  nurse. 

(e)  That  if  the  Division  of  Health  is  willing,  the  Association  be  notified  of  all 
typhoid,  pneumonia,  measles,  whooping  cough,  scarlet  fever  and  diphtheria  cases  re- 
ported, and  such  patients  be  visited  wherever  the  doctor  in  charge  is  willing. 

(f)  That  arrangement  be  made  with  the  Division  of  Health  to  have  district  phy- 
sicians, as  a  routine  practice,  notify  the  Association  of  all  patients  visited,  excepting  only 
cases  referred  at  once  to  hospitals,  and  those  discharged  on  the  first  visit. 

(g)  That  more  attention  be  paid  to  the  health  of  the  family  and  the  teaching  of  hy- 
giene in  the  homes. 

ADMINISTRATION 

(a)  That  the  staff  be  enlarged  to  meet  the  needs  of  the  extended  activities  recommended 
above.  This  will  probably  mean  doubling  the  staff  now,  and  as  these  activities  grow, 
doubling  it  again. 

(b)  That  as  the  staff  is  increased  the  number  of  supervisors  be  increased  to  keep 
the  ratio  at  approximately  one  supervisor  for  every  ten  nurses. 


78£  Hospital  and  Health  Survey  ' 

(c)  1   That  one  automobile  be  provided  for  each  sub-station  for  use  especially  in  the 

outlying  districts;  thus  also  making  possible  more  frequent  visits  of  the  super- 
visors, especially  to  the  outlying  districts. 

2  That  as  an  alternative,  the  nurses  in  the  outlying  districts  be  provided  with  a 
sub-station,  and  come  in  to  the  district  station  only  two  or  three  times 
a  week.  To  these  outlying  districts  the  older  and  more  experienced  nurses 
should  be  assigned. 

(d)  That  the  Pilgrim  nurse  report  to  the  West  Side  station  and  that  the  boundaries  of 
the  Pilgrim  District  and  the  neighboring  districts  be  changed  to  bring  about  a  more  advan- 
tageous arrangement.  The  nurse  could  still  maintain  a  dispensary  service  at  the  church  if 
desired. 

(e)  That  the  individual  nurses'  districts  be  made  the  unit  of  work,  giving  them  a 
fixed  number  or  letter,  and  requiring  a  statistical  report  for  each  of  these  units  monthly, 
and  that  the  unit  of  district  work  be  the  official  census  tracts,  singly  or  in  multiples. 

(f)  That  the  individual  nurse  report  to  the  district  office  only  once  a  day. 

(g)  That  the  amount  of  supervision  of  the  nurses  in  the  field  be  increased  and  be 
lessened  in  the  station. 

(h)  That  the  nurses  attend  Associated  Charities'  case  conferences  more  frequently. 

(i)  That  methods  be  devised  of  developing  the  individual  initiative  and  resources  of 
the  nurses  (a  weekly  round  table  is  suggested  for  the  discussion  by  the  staff,  of  district 
problems,  case  work,  and  allied  subjects.)  The  nurses  themselves  might  well  plan  and 
conduct  these  round  tables. 

(j)  That  a  record  of  the  source  of  calls  be  kept. 


Nursing  Service  of  tne  Board  of  Education 

IN  school  nursing,  as  in  the  other  branches  of  public  health  nursing,  Cleve- 
land is  fortunate  in  having,  through  the  agency  of  the  Central  Nursing 
Committee,  a  high  professional  standard.  In  school  nursing,  as  in  the 
other  branches,  a  valuable  demonstration  of  work  has  been  made.  A  fine 
spirit  and  diligent  application  have  been  found  throughout  the  department. 
The  failures  which  have  disclosed  themselves  in  the  course  of  this  investi- 
gation are  in  the  main  due  to  the  same  causes  as  those  in  various  other  organ- 
izations studied:  that  is  inadequacy  in  numbers  and  faulty  supervision. 
Yet  there  is  every  reason  to  think  that  with  adequate  enlargement  of  the 
staff,  with  proper  supervision,  and  with  a  change  of  emphasis  in  the  work  to 
reduce  some  of  the  less  important  activities  and  strengthen  the  more  essen- 
tial features,  a  school  nursing  system  second  to  none  can  be  built  up. 

Scope  of  the  Work 

1.  Assisting  medical  inspector  with  physical  examination  of  children. 

Every  school  child  receives  one  examination  a  year;    some  of 
those  found  to  be  defective  are  examined  more  than  once. 


Nursing  783 

%.  Inspection  of  pupils  by  class  rooms. 

After  the  summer,  Christmas  and  Easter  vacations,  the  children 
are  inspected,  a  room  at  a  time,  by  the  doctor  and  nurse,  for  signs 
of  communicable  disease,  skin  disease,  running  ears,  or  pediculosis. 
Once  a  month  the  nurse  makes  a  similar  inspection,  devoting  about 
7  to  10  minutes  to  an  entire  roomful  of  children. 

3.  Securing  correction  of  defects  found  through  the  examinations  by 
means  of: 

Notes  and  messages  sent  to  parents, 

Consultations  with  parents  at  the  school  house, 

Visits  to  the  home. 

4.  Maintenance  of  "dispensary  hour"  in  each  school  for: 

Treatments, 

Dressings, 

Emergencies, 

Inspection  of  excluded  children. 

5.  Health  talks  to  individual  pupils. 

6.  Health  talks  to  classes  in  class  rooms. 

The  Staff 

The  staff  of  the  nursing  bureau  consists  of: 

1  supervisor  of  nurses, 

2  field  nurses, 
30  staff  nurses, 

6  junior  health  workers, 

1  stenographers  (part  time  only). 

There  is  a  central  office  in  the  administrative  building,  but  there  are  no 
branch  offices. 

Analysis  of  Activities 

Examination  of  Children 

Since  these  examinations  are  made  by  the  medical  inspectors  they  need 
no  comment  in  a  study  of  nursing  work.  They  are  made  rather  rapidly, 
usually  without  the  taking  of  medical  histories,  and  except  in  a  few  instances, 
they  are  not  complete  examinations.  Moreover,  most  of  the  corrections 
recommended  are  routine  recommendations,  such  as  removal  of  tonsils  and 
adenoids,   and  treatment  for  dental   and  visual   defects.     It  would   seem. 


784  Hospital  and  Health  Survey 

therefore,  that  the  school  nurses  might  be  released  from  attending  the  doc- 
tor during  these  examinations,  and  be  replaced  by  junior  health  workers, 
thus  saving  much  of  the  nurses'  time  for  more  productive  work.  Where 
less  obvious  and  simple  conditions  are  found,  and  treatment  is  more  tech- 
nical and  personal,  the  nurse  should  consult  with  the  doctor,  in  order  to 
receive  more  detailed  instruction  than  is  written  on  the  record. 

Inspection  of  Pupils  by  Rooms 

The  nurse  spends  an  hour  or  more  each  school  day  in  making  room  in- 
spections, for  the  purpose  of  detecting  skin  lesions,  running  ears,  pediculosis, 
and  symptoms  of  communicable  diseases.  These  examinations  of  an  entire 
roomful  of  children  are  completed  in  7  to  10  minutes.  On  account  of  the 
preoccupation  of  the  nurse  with  other  duties,  even  these  necessarily  super- 
ficial inspections  can  be  repeated  only  at  intervals  of  about  4  weeks.  Be- 
tween examinations  the  teacher  must  be  relied  upon  to  notice  symptoms 
and  to  refer  children  to  the  nurse  during  the  "dispensary  hour."  Since 
previous  training  and  experience  in  such  work  cannot  be  expected  of  teachers, 
the  nurse  should  not  only  determine  the  physical  condition  of  the  children 
at  the  time  of  her  visit,  but  should  also  confer  with  the  teacher  and  instruct 
her,  so  that  she  may  render  this  service  to  the  best  of  her  ability  during  the 
long  intervals  between  the  nurse's  visits.  Teachers  who  are  cooperative  and 
become  fairly  proficient  will  need  less  frequent  visits  from  the  nurse,  and 
more  attention  can  be  given  to  school  rooms  of  those  who  are  new  or  less 
interested.  This  cooperation  between  the  nurse  and  the  teacher  should 
result  in  more  effective  supervision  of  the  health  of  the  children  day  by  day, 
than  is  now  possible. 

Correction  of  Defects — Lack  of  Home  Visiting 

The  most  important  activities  of  school  nurses  are  arranging  for  the 
correction  of  defects,  the  improvement  of  conditions  personal  or  environ- 
mental causing  defects,  and  the  establishment  of  better  health  habits. 

In  the  case  of  many  children,  a  real  remedy  for  an  abnormal  condition 
cannot  be  prescribed  until  the  child's  environment  has  been  studied.  Change 
in  the  mode  of  living  is  often  essential  not  only  to  the  correction  of  physical 
defects,  but  also  to  the  complete  restoration  and  maintenance  of  health. 
These  changes  in  living  can  be  accomplished  in  most  cases  only  by  thought- 
ful persuasive  visits  during  which  the  nurse  may  talk  over  the  child's  condi- 
tion at  length  with  the  parent,  may  discover  what  influences  in  his  home 
life  are  harmful,  or  what  may  be  wrong  in  his  hygienic  habits,  and  may 
advise  the  mother  thoroughly  and  carefully  concerning  any  changes  needed. 
Such  visits  are  the  very  heart  of  school  nursing. 

Thus,  for  instance,  a  boy  in  one  of  the  Cleveland  schools,  who  had  had 
skin  trouble  since  babyhood,  had  been  to  many  doctors  and  dispensaries 
without  relief.  It  was  discovered  by  the  nurse  in  a  home  visit  that  his  diet 
consisted  chiefly  of  tea,  coffee  and  sweets.  "We've  plastered  him  with  the 
things  the  doctors  were  experimenting  with,"  said  his  family,  "but  nothing 
helped  until  you  got  after  his  food." 


Nursing  785 

In  Cleveland,  at  present,  much  time  is  given  to  finding  defects  and  to 
recommending  treatment;  little  time  is  given  to  seeing  that  those  defects 
are  remedied  and  that  the  child's  mode  of  life  and  surroundings  are  improved. 
Reliance  is  placed  largely  on  sending  notifications  to  the  parents,  and  on 
consultation  with  parents  in  the  schools.  It  is  apparent  that  the  results  of 
this  practice  are  not  wholly  satisfactory.  The  school  records  for  the  war 
year  1917-1918  show  that  32,918  children  were  found  to  have  defects,  of 
which  12,544  or  38.1%  were  corrected.  6,397  consultations  with  parents 
were  held,  and  many  of  these  consultations  may  have  been  return  visits 
of  the  same  parents.  During  that  year  the  nurses  made  only  9,010  visits 
to  the  homes.  This  small  number  should  be  in  part  ascribed  to  the  fact 
that  the  nurses  assisted  in  a  very  large  number  of  vaccinations  during 
the  year,  over  45,000  as  against  approximately  16,000  in  the  next  year. 

During  1918-1919,  only  2,789  consultations  with  parents  were  held, 
but  the  nurses  made  13,544  visits  to  homes.  The  defects  corrected  num- 
bered 43.6%  of  the  total  number.  So  many  factors  enter  into  the  correcting 
of  defects  that  it  would  be  unjust  to  draw  final  conclusions  from  the  numbers 
given;  nevertheless  the  increase  in  the  number  of  corrections  is  striking 
when  compared  with  the  increased  number  of  home  visits,  even  though 
the  number  of  consultations  with  parents  at  the  schools  showed  a  decrease. 

Various  duties  within  the  school  buildings  engage  the  nurses  until  the 
middle  of  the  afternoon.  They  are  consequently  unable  to  spend  more 
than  one  hour  and  a  half  a  day,  and  one  half -day,  in  visiting  the  homes  of 
the  children,  a  total  of  perhaps  ten  hours  a  week  out  of  thirty-eight  and  a 
half.  Furthermore,  constructive  case  work  appears  to  be  almost  unknown. 
The  follow-up  in  the  homes  appears  to  consist  chiefly  of  brief  visits,  or,  as 
the  nurses  describe  them,  "flying  visits"  made  to  obtain  the  parents' 
consent  to  an  operation  or  other  correctional  treatment,  instead  of  careful 
repeated  health  teaching  without  which  a  high  degree  of  success  is  im- 
possible.    The  need  for  more  and  better  home  visiting  is  clearly  indicated. 

Dispensary  Service 

Nearly  half  of  the  nurses'  time  is  spent  in  the  dispensaries,  where  much 
of  the  work  consists  in  giving  treatments  and  doing  dressings.  Just  how 
necessary  it  is  for  the  nurses  to  spend  so  large  a  share  of  their  time  in  dispf n- 
sary  work  can  only  be  determined  by  further  observation.  A  careful 
analysis  should  be  made  to  determine  whether  the  time  could  not  be  re- 
duced without  detriment  to  the  work. 

Individual  Health  Talks 

The  dispensary  work  observed  was  too  hurried  to  permit  individual  health 
talks  to  the  pupils.  In  some  of  the  smaller  schools  it  is  possible  that  more 
time  may  be  given.  To  be  effective  such  talks  should  be  simple,  slow, 
painstaking,  and  repeated  more  than  once.  A  single,  rather  hasty  health 
talk  to  a  child  needing  correction  is  of  doubtful  value.  Even  a  satisfactory 
talk  would  be  far  more  efficacious  if  repeated  to  him  at  home,  after  talking 
with  his  mother  and  studying  his  home  life. 


786  Hospital  and  Health  Survey 

Health  Talks  to  Classes 
These  talks  on  health  habits  could  be  very  valuable  if  given  according  to 
a  definite  graded  schedule  and  system,  in  a  regular  orderly  fashion.  There 
is  a  great  difference  in  the  subject  matter  and  manner  of  presenting  it  to 
first  grade  pupils  and  eighth  grade  pupils.  The  present  unstandardized, 
ungraded,  and  unsystematic  method  renders  these  talks  of  little  value. 
They  should  be  made  a  definite  part  of  the  curriculum  of  every  grade,  and 
should  be  given  by  the  teachers  whenever  the  nurses  do  not  have  time  to 
give  them  in  this  way.  The  present  staff  would  not  have  time  to  give  such 
systematic  instruction. 

Analysis  of  Staff  and  Administrative  Methods 

Supervisor 

The  supervision  of  this  nursingservice  is  lodged  in  the  hands  of  one  super- 
visor and  two  field  nurses.  While  the  spirit  arid  intentions  of  the  supervisor 
are  excellent,  there  are  certain  marked  shortcomings  in  the  conduct  ofjj  the 
work.  Not  only  are  there  too  few  supervisors  for  the  size  of  the  staff,  but 
the  purpose  and  aims  of  supervision  are  apparently  misconceived. 

It  would  assist  the  supervisor  to  carry  the  responsibilities  of  her  position 
if  she  were  advanced  in  rank.  She  should  have  the  title  and  salary  of  director 
or  superintendent  of  nurses. 

Field  Nurses 
One  field  nurse  has  eight  nurses  assigned  to  her,  and  in  addition  is  respon- 
sible for  staff  nurse  duties  in  one  school  and  one  eye  clinic.     She  therefore 
gives  only  half  her  time  to  supervisory  duties.     The  other  field  nurse  has 
22  nurses  under  her. 

The  field  nurses  in  their  supervisory  capacity  are  expected  to  visit  only 
those  staff  nurses  who  have  been  newly  appointed,  or  who  are*  thought  to 
need  special  supervision.  Last  year  several  of  the  staff  nurses  received  no 
supervisory  visits  from  a  field  nurse. 

Both  of  these  nurses  spend  much  of  their  time  in  substituting  for  sick 
nurses  and  the  rest  in  training  new  nurses  and  laboring  with  poor  ones. 
The  good  nurses  have,  therefore,  none  of  the  benefits  of  supervision. 

Radical  change  is  needed  here.  These  nurses  should  have  the  rank, 
title,  position,  and  salary  of  supervisors.  None  of  them  should  have  any 
staff  work  to  do  as  is  now  the  case  on  the  West  Side.  As  a  matter  of  routine 
they  should  spend  two  half-days  a  month  with  each  of  their  staff  nurses, 
one  half -day  with  her  in  the  field,  and  the  other  half  in  the  school. 

To  make  proper  supervision  possible,  it  will  be  necessary  to  increase  the 
number  of  supervisors.  There  should  be  one  supervisor  for  every  ten  nurses 
at  most. 

Each  supervisor  should  have  an  office  in  her  district.  She  should  be 
responsible  for  the  management  of  her  district,  and  the  work  of  the  nurses 
in  it.  She  should  hold  definite  office  hours,  when  any  of  her  staff  can  find 
her  for  consultation.  The  staff  should  be  encouraged  and  expected  to 
consult  her  frequently  about  case  work.     When  the  value  of  case  work  is 


Nursing  787 

taught  and  practised,  the  staff  will  have  many  problems  to  consult  her  about. 
At  present  they  have  few. 

It  is  important  to  have  monthly  statistical  reports  made  by  each  staff 
nurse,  studied  and  corrected  by  each  supervisor  and  then  referred  to  the 
superintendent  or  director.  At  present  daily  reports  are  made  by  the  nurses, 
and  these  are  summarized  monthly  in  the  main  office.  A  personal  record  of 
efficiency  and  personality  of  each  of  her  staff  should  be  prepared  by  the 
supervisor,  after  careful  observation  of  the  nurse  and  study  of  her  work, 
and  transmitted  every  three  months  to  the  director,  for  permanent  record. 
Such  records  should  be  prepared  monthly  for  new  nurses  for  the  first  three 
months. 

In  some  measure  the  deficiencies  apparent  in  the  work  are  due  to  the 
fact  that  the  number  of  nurses  and  supervisors  is  inadequate.  But  from  the 
analysis  of  administration  it  is  clear  that  the  most  serious  weaknesses  in  the 
system  arise  from  the  failure  to  appreciate  that  the  supervisor  is  to  be  a  leader 
and  consultant,  whose  duty  it  is  to  develop  her  staff,  to  help  them  see  and 
meet  their  problems,  to  train  their  faculties  and  correct  their  mistakes,  to 
analyze  their  work  and  its  results.  The  absence  of  such  supervision  is  evi- 
dent in  the  nurses'  work,  which  is  often  routine  in  character,  lacking  in  origi- 
nality and  in  grasp  of  opportunity. 

Nurses 
The  staff  nurses  seem  to  be  faithful,  honest  workers,  performing  their 
duties  conscientiously,  but  it  is  quite  obvious  that  they  lack  sufficient  super- 
vision.    They  clearly  show  a  lack  of  leadership  and  development. 

They  have  too  many  children  (approximately  3,000  per  nurse)  and  too 
many  school  duties  to  accomplish  the  very  necessary  home  visiting.  The 
staff  should  be  increased  to  give  a  ratio  of  1  nurse  to  every  2,000  children, 
if  a  junior  health  worker  is  provided  for  each  nurse.  Otherwise  the  ratio 
should  be  one  nurse  to  every  1,500  children.  There  might  be  provided  with 
much  benefit  to  the  service  one  "floating  nurse"  under  each  supervisor  to 
fill  the  place  of  sick  nurses. 

Junior  Health  Workers 
These  workers  seem  to  be  of  a  unique  type,  originated  and  developed  in 
Cleveland,  on  the  whole  with  very  good  results,  which  are  largely  due  to 
their  being  well  educated.     All  of  them  are  college  graduates. 

They  have  relieved  the  nurses  of  much  routine  work  in  attending  the 
doctor  during  examinations,  have  been  responsible  for  getting  dental  defects 
corrected,  and  have  taken  many  children  to  dispensaries.  There  seems  to 
be  no  reason  why  all  of  this  work  could  not  be  given  to  them.  Placing  one 
health  worker  with  each  nurse  would  result  in  freeing  the  nurse  for  more 
important  duties. 

On  the  other  hand,  to  allow  home  visits  to  be  made  by  these  workers, 
to  secure  information  about  children  to  whom  Binet  tests  have  been  given, 
and  those  referred  to  dispensaries,  appears  to  be  a  mistake.  Such  visits, 
especially  the  first  named,  give  much  opportunity  for  constructive  health 
work,  and  require  a  trained  discrimination  in  observation  of  health  as  well 
as  social  conditions.     They  should,  therefore,  be  transferred  to  the  nurses. 


788  Hospital  and  Health  Survey 

Conferences 
In  order  to  promote  the  enthusiasm  and  inspiration  which  comes  from 
the  rivalry,  competition  and  spirited  discussion  of  new  and  live  topics, 
weekly  meetings  of  the  nurses  are  held  each  Saturday  morning,  of  the  whole 
group  or  of  sections  of  the  nurses  according  to  the  size  of  assembly  rooms 
available  at  the  headquarters  or  elsewhere.  Unless  interest  in  these  meet- 
ings is  well  maintained,  perhaps  in  part  by  bringing  in  outside  speakers 
as  occasion  offers,  but  chiefly  by  prepared  discussions  by  members  of  the  staff, 
the  object  of  the  meetings,  that  is,  the  building  up  of  esprit  de  corps  and 
unity  in  the  staff,  will  be  missed.  From  time  to  time  these  should  be  turned 
into  carefully  prepared  case  conferences,  at  which  certain  cases  presenting 
difficulties,  solved  or  unsolved,  should  be  presented.  Such  conferences  will  do 
much  to  arouse  in  the  nurse  a  sense  of  the  importance  of  good  case  work  and 
a  knowledge  of  the  way  to  go  about  it.  For  the  same  reason  the  nurses  should 
be  encouraged  to  attend  the  case  conferences  of  the  Associated  Charities. 

Records 

At  present  there  is  little  coordination  in  the  records.  The  child's  indi- 
vidual record  is  kept  in  the  school  room.  This  record  is  very  brief  and  tells 
little  of  what  is  done  for  the  child.  The  doctor's  orders  are  on  this  card. 
The  work  done  by  the  nurse  is  usually,  though  not  always,  entered  on  the 
correction  slip  in  her  file.  Home  visits  are  kept  on  still  another  card.  An 
effort  to  check  the  nurse's  accomplishment  against  the  doctor's  recommenda- 
tion is  almost  hopeless. 

The  individual  health  record  of  the  child  is  keut  on  the  teacher's  desk, 
supposedly  to  keep  the  teacher  informed  of  the  child's  physical  condition. 
These  records  follow  the  child  from  room  to  room  together  with  his  school 
record.  The  teachers,  however,  are  uninterested  because  nothing  appears 
on  this  record  that  would  give  them  a  clear  idea  of  the  child's  physical  con- 
dition. Therefore,  it  would  seem  much  more  intelligent  to  have  this  record 
kept  in  the  dispensary  with  the  other  records,  and  have  them  so  arranged 
that  it  would  be  possible  to  know  the  entire  performance  of  health  work  in 
regard  to  each  child,  unless,  as  proposed  on  page  312  of  the  child  health 
report,  the  records  in  the  school  room  include  all  items  of  the  child's  health 
history  as  they  should.* 

The  method  of  using  the  correction  slips  for  notations  of  home  visits 
and  corrections  accomplished  i&  exceedingly  bad.  It  does  not  make  for  per- 
manency, and  there  is  no  way  of  using  them  as  a  basis  for  statistical  study. 
The  absence  of  a  monthly  report  from  the  nurse  is  also  a  factor  in  making  it 
difficult  to  know  what  the  nurse  has  actually  accomplished.  A  simple, 
accurate,  and  comprehensive  report  should  be  made  by  the  nurse  every 
month  as  a  part  of  the  whole  statistical  report.  In  no  other  way  can 
she  keep  a  check  on  her  own  activities,  know  what  she  has  accomplished, 
and  measure  her  progress. 

RECOMMEND  A  TIONS 

The  following  recommendations  are  directed  toward  concentrating  the  work  of  the 
nurses  on  the  more  essential  activities,  which  they  alone  can  conduct. 
*  A  new  cumulative  record  card  has  already  been  developed. 


Nursing  789 

ACTIVITIES 

(a)  Staff  nurses  should  be  released  from  assisting  doctors  with  examination  of  the 
children,  and  replaced  by  junior  health  workers. 

(b)  Room  inspection  should  be  made  by  nurse  and  teacher  in  cooperation. 

(c)  In  correction  of  defects,  efforts  should  be  concentrated  on  home  visits,  thus  chang- 
ing the  present  emphasis. 

(d)  The  work  done  during  the  "dispensary  hour"  should  be  further  analyzed,  and  the 
time  reduced,  if  possible. 

(e)  Individual  health  talks  should  be  given  to  children  at  home,  with  explanations  to 
the  mother. 

(f)  Class  room  talks,  graded  and  standardized,  should  be  given  as  a  regular  part  of  the 
curriculum. 

(g)  An  elementary  course  of  instruction  in  the  principles  of  teaching  should  be  ar- 
ranged for  the  nursing  staff. 

ADMINISTRATION 

(a)  The  present  rank  of  supervisor  should  be  advanced  to  that  of  superintendent  or 
director. 

(b)  The  two  field  nurses  should  be  advanced  to  rank,  title  and  salary  of  supervisors, 
"and  the  number  of  supervisors  increased  in  the  ratio  of  1  to  every  10  staff  nurses.  • 

(c)  Each  supervisor  should  be  held  responsible  for  the  management  of  her  district 
and  the  work  of  her  nurses.    - 

(d)  Each  supervisor  should  have  an  office  in  her  district.  She  should  keep  office 
hours  for  consultation  with  her  staff. 

(e)  The  staff  should  be  increased  by  30  nurses.  The  number  of  schools  under  each 
nurse  should  be  decreased. 

(f)  The  number  of  health  workers  should  be  increased  in  proportion  to  the  increase 
in  the  nursing  staff,  but  only  in  case  well  educated  women  can  be  obtained  for  these 
positions. 

(g)  Weekly  staff  conferences  should  be  continued. 

(h)  The  staff  should  attend  Associated  Charities'  conferences  frequently. 

(i)  The  record  system  should  be  reorganized  to  provide  coordination  of  the  individual 
child's  records.  A  monthly  statistical  report  should  be  made  by  each  nurse.  Every 
four  months  an  efficiency  record  for  each  nurse  should  be  made  by  the  supervisor. 

The  University  Public  Health  Nursing  District 

AS  described  in  the  report  on  Nurses'  Education  in  Cleveland,  a  course 
in  public  health  nursing  is  given  by  Western  Reserve  University  under 
the  School  of  Applied  Social  Science.  The  details  of  the  organization, 
management,  finances,  etc.,  of  the  University  District,  are  described  in  that 
record  and  need  not  be  repeated  here. 

The  unique  character  and  opportunity  of  the  University  District  as  a 
practice  field  have  been  commented  on.  It  remains  to  describe  the  Uni- 
versity District  as  a  community  service  of  the  first  order;  that  is,  as  a  demon- 
stration of  nursing  almost  entirely  generalized  and  carried  out  with  a  marked 
degree  of  success. 

The  University  District  is  an  area  set  aside  for  the  practical  training  of 
public  health  nurse  students  in  which  the  activities  elsewhere  carried  on  by 
the  Nursing  Service  of  the  Division  of  Health  and  the  Visiting  Nurse  Asso- 
ciation, are  performed  by  the  students  under  the  direction  of  an  independent 


790  Hospital  and  Health  Survey 

teaching  staff.  The  area  coincides  with  Health  District  No.  8,  estimated  at 
60,000  to  70,000  population.  It  is  one  of  the  most  congested  and  poorest 
parts  of  the  city. 

Analysis  of  Administration 

Staff 

The  director  of  the  course  and  of  the  field  work  is  a  public  health  nurse 
on  the  University  payroll  as  an  assistant  professor.  She  teaches  one  course 
at  the  University  and  is  in  general  charge  of  the  district,  teaching  and  super- 
vising the  students  and  performing  all  the  administrative  duties.  The  direc- 
tor's duties  are  many  and  difficult,  and  are  indeed  beyond  the  capacity  of 
one  person.  A  full-time  assistant  director  is  needed  to  take  over  many 
routine  matters,  so  that  the  head  may  have  free  time  for  the  more  important 
duties  of  her  position. 

Assisting  her  are  five  nurse  instructors,  one  of  whom  is  designated  assist- 
ant director,  with  limited  administrative  duties.  Each  instructor  is  a  pub- 
lic health  nurse  in  charge  of  a  part  of  the  district  and  responsible  for  the 
students  assigned  to  her  area.  The  district  is  thus  divided  among  these  five 
supervisors,  as  is  also  the  management  of  the  clinics  held  in  the  district. 
Each  instructor  is  in  addition  responsible  for  the  teaching  of  certain  practical 
subjects,  particularly  those  in  which  she  has  had  special  experience. 

There  is  no  other  permanent  staff.  With  the  exception  of  school  nursing 
and  out-patient  maternity  work,  nursing  in  the  district  is  done  by  the  stu- 
dents of  the  course  as  a  part  of  their  training.  The  number  of  students  actu- 
ally at  work  in  the  district  at  any  one  time  varies.  There  are  graduate 
students  who  are  taking  the  full  course,  and  others  who  are  taking  only  the 
four  months'  practical  work.  There  are  also  ten  undergraduate  students 
sent  from  nurses'  training  schools  for  two  months'  experience.  The  highest 
number  in  the  field  during  the  past  year  has  been  33  and  the  lowest  10. 

There  are  also  an  office  secretary,  a  business  woman,  who  is  responsible 
for  many  business  details,  and  three  typists. 

.    Plan 

The  district  is  divided  into  five  sections,  each  in  charge  of  an  instructor. 
These  sections  are  again  divided  into  sub-sections,  one  for  each  student  nurse. 
The  number  of  nurses  in  each  section  ranges  from  two  to  six  or  seven.  Each 
student  nurse  has  full  responsibility  for  her  sub-section  in  which  she  carries 
on  a  generalized  service,  under  the  direction  of  her  instructor. 

Analysis  of  Activities 

Visiting  Nursing 

General  visiting  for  free,  part-pay  and  full-pay  patients  and  for  Metro- 
politan Life  Insurance  policy  holders  is  carried  on  in  this  district  exactly  as 
done  elsewhere  by  the  Visiting  Nurse  Association,  with  the  exception  of 
attendance  at  confinements  and  minor  operations.     The  student  staff  is  also 


Nursing  791 

entrusted  with  the  nursing  care  which  in  other  parts  of  the  city  is  given  by 
the  nurses  of  the  Division  of  Health.  Owing  to  the  character  of  the  popula- 
tion there  is  little  call  for  hourly  nursing. 

Because  of  the  difference  in  the  size  of  their  respective  districts,  it  is  diffi- 
cult to  compare  the  amount  of  nursing  done  by  the  University  District 
Staff  with  that  of  the  Visiting  Nurse  Association.  Apparently  there  is  little 
difference  either  in  volume  or  quality,  except  that,  because  of  the  generalized 
character  of  their  nursing,  the  University  students  are  able  to  give  more 
attention  to  the  family  as  a  whole.  Certainly  visiting  nursing  has  not  suf- 
fered by  being  made  a  part  of  this  generalized  service. 

Owing  to  the  higher  ratio  of  nurses  to  population  in  this  district,  the  at- 
tention given  to  sick  babies  and  tuberculosis  patients  can  be  more  regular 
and  thorough  than  that  given  elsewhere  by  the  nurses  of  the  Division  of 
Health.  As  much  emphasis  is  put  on  nursing  care  as  on  any  other  aspect  of 
the  work,  and  full  provision  is  made  for  it.  In  fact,  as  high  a  standard  of 
care  is  given  to  these  patients  as  to  other  bed  patients  at  home. 

Child  Hygiene 

This  service  in  the  University  District  is  similar  in  scope  to  that  of  the 
Nursing  Service  of  the  Division  of  Health.  One  or  two  exceptions  are  noted; 
all  babies  whose  births  are  reported  are  visited  and  cases  under  the  care  of 
a  private  doctor  are  not  dismissed. 

In  January,  1920,  there  were  510  well  babies  attending  the  Prophylactic 
Clinic,  1,885  well  babies  not  attending  the  clinic,  843  sick  and  convalescent 
babies  attending  the  Babies'  Dispensary  and  Hospital,  and  21  babies  under 
private  doctors;  a  total  of  3,259  babies  under  three  years  of  age,  or  about  100 
babies  to  each  student  nurse.  Two  or  three  children  are  often  in  the  same 
home.  The  babies  attending  the  clinic  regularly  are  visited  two  or  three 
times  every  six  months.  Sick  cases  are  seen  daily,  or  as  often  as  necessary. 
Well  babies  not  attending  clinic  are  seen  when  possible,  sometimes  two  to 
six  moiths  elapsing  between  visits.  The  director  and  instructors  think  it  is 
worth  while  to  carry  these  well  babies  even  though  they  are  not  seen  fre- 
quently. The  records  show  that  the  average  is  five  visits  a  month  per 
baby.  The  record  also  shows  that  a  large  proportion  of  the  new  babies 
taken  on  each  month  are  discovered  by  the  nurses  themselves  as  they  go  about 
on  other  errands  among  their  families.  The  best  of  nursing  care,  as  has  been 
stated  above,  is  given  to  sick  babies.  It  would  be  desirable  to  have  well 
babies  likewise  visited  more  frequently. 

Tuberculosis 

The  scope  of  tuberculosis  work  done  by  the  University  District  corre- 
sponds with  that  done  by  the  Nursing  Service  of  the  Division  of  Health. 
There  is  no  tuberculosis  clinic  in  this  district,  patients  being  referred  to 
Health  Center  No.  2,  unless  able  to  have  a  private  doctor. 

It  was  evident  that  the  patients  were  being  well  cared  for  and  kept  under 
watchful  supervision.     But  although  the  nurses  are  willing  and  able  to  give 


79-2  Hospital  axd  Health  Survey 

all  the  bedside  care  necessary,  they  find  that  little  is  needed.  Most  of  their 
cases  are  ambulatory,  many  of  them  working,  and  very  few  bedridden. 
Advanced  cases  are  persuaded  to  go  to  the  hospital.  It  is  believed  that  if 
there  were  many  bedridden  cases  in  the  district  not  under  the  care  of  the 
nurses,  the  fact  would  be  known.  The  nurses  are  eager  to  find  all  such  pa- 
tients. Just  as  in  the  case  of  children,  the  nursing  is  far  more  adequate  and 
of  a  higher  standard  throughout  than  that  given  by  the  nurses  of  the  Division 
of  Health,     i 

The  nurses  believe  that  they  are  in  touch  with  the  majority  of  cases 
showing  marked  symptoms,  but  that  there  are  probably  a  number  of  other 
cases  missed  for  the  following  reasons: 

1.  Because  the  men  are  away  at  work  all  day  when  the  nurse  is  about, 
and  no  one  in  the  family  thinks  that  they  are  sick  enough  to  report  to  her. 

2.  Because  early  cases  conceal  the  fact  that  they  are  losing  weight  or 
showing  symptoms,  and  unless  a  nurse  happms  to  see  them  she  is  not  told  of 
them  by  the  patients  or  family. 

3.  Because  patients,  both  incipient  and  advanced,  have  more  money 
than  before  the  war  and  go  to  private  doctors  who  often  fail  either  to  diag- 
nose the  case,  or  to  report  it.  Patients,  moreover,  change  doctors  frequently 
and  are  often  not  under  observation  long  enough  to  give  them  a  chance  to 
diagnose  or  report  the  case,  or  else  the  doctor  does  not  tell  the  patient  what 
is  the  matter,  for  fear  he  will  go  to  another  practitioner.  Many  such  cases 
used  to  go  to  the  dispensary. 

4.  Because  the  district  includes  many  people  of  limited  education  and 
opportunity,  the  last  to  appreciate  a  subtle  or  hidden  danger. 

For  the  same  reasons  the  nurses  believe  that  they  are  getting  only  fair 
results  in  their  efforts  to  persuade  positive  and  suspicious  cases  and  those 
who  have  been  exposed  to  infection  to  go  to  the  tuberculosis  clinic. 

Similarly  the  nurses  find  it  difficult  to  persuade  members  of  the  family 
to  be  examined;  they  refuse  to  see  the  necessity  of  going  to  a  clinic  if  they 
feel  well. 

Patients  soon  grow  restless  in  the  hospitals.  They  complain  of  poor 
food  or  of  being  lonesome,  and  come  home  as  soon  as  they  are  a  little  better, 
long  before  their  malady  is  arrested.  Many  go  back  to  work  soon  after 
returning  home. 

A  report  of  January,  1920,  shows  that  out  of  209  positive  cases  on  the 
books,  159  were  attending  a  clinic;  and  out  of  1,060  suspicious,  non-tuber- 
culous and  exposed  cases,  881  were  attending  a  clinic. 

The  records  further  show  that  the  average  number  of  visits  per  month 
per  patient  for  the  whole  group  is  only  .3.  If  the  visits  were  restricted  to 
the  positive  cases  only,  the  average  would  be  1  visit  per  month  per  patient. 
From  this  it  is  plain  that  the  visits  should  be  more  frequent.  At  present 
each  nurse  averages  30  patients,  under  observation. 


Nursing  793 

Communicable  Disease  Control 

The  Division  of  Health  reports  all  communicable  diseases,  except  small- 
pox, promptly  to  the  University  District.  The  nurses  visit  all  of  them, 
reportable  and  not  reportable,  for  the  following  purposes: 

To  place  and  remove  placards. 

To  instruct  in  care,  isolation  and  prophylaxis. 

To  issue  work  permits. 

To  give  nursing  care. 

To  take  cultures. 

To  maintain  quarantine. 

The  nurses  find  that  through  this  work  they  have  an  excellent  chance  to 
give  care,  to  teach,  and  to  be  helpful  to  the  family  when  most  needed.  The 
nurses  perhaps  lose  some  of  their  popularity  because  of  restrictions  which 
they  must  place  on  freedom  of  movement,  but  on  the  whole  the  family  does 
not  harbor  resentment  against  them. 

No  great  amount  of  nursing  care  is  needed  because  both  private  and  city 
doctors  send  most  of  the  very  sick  cases  to  the  hospital.  The  District  serv- 
ice is  willing  and  prepared  to  give  as  much  nursing  care  as  is  needed.  Teach- 
ing the  family  and  caring  for  the  patient  are  considered  of  as  much  impor- 
tance as  maintaining  quarantine,  issuing  permits,  or  taking  cultures.  Nurs- 
ing care  has  been  given  to  the  few  cases  of  typhoid  which  have  been  reported. 
Pneumonia  has  not  been  reported  to  the  University  District  by  the  Divi- 
sion of  Health.     It  would  seem  well  to  have  these  cases  reported  also. 

This  work  occupies  about  one-sixth  of  the  nurses'  time. 

Prevention  of  Blindness 

The  University  District  provides  care  for  trachoma  cases,  but  has  not 
undertaken  to  be  responsible  for  opthalmia  neonatorum. 

Midwife  Supervision 
This  service  has  not  been  taken  over  for  the  Division  of  Health. 

Supervision  of  Boarding  Homes  for  Babies 

There  are  only  four  of  these  homes  in  the  District,  and  they  receive  the 
same  oversight  and  supervision  as  other  homes  in  the  District  in  which  there 
are  babies.  There  is  no  doubt  that  more  care  and  supervision  should  be 
given  to  this  group  of  infants. 

Prenatal  Nursing 

The  nurses  find  most  of  the  pregnant  cases  while  they  are  out  in  the  Dis- 
trict and  in  the  homes.     Doctors  do  not  report  very  many,  and  midwives 


794  Hospital  and  Health  Survey 

only  a  few.  Births  reported  from  this  district  to  the  Division  of  Health  in 
1918  were  1,618;  for  1919  the  figures  were  not  obtainable.  In  1919  the  Uni- 
versity District  had  479  pregnant  women  attending  clinic  and  almost  as  many 
more  under  supervision  at  home.  In  the  opinion  of  the  director,  one  in 
every  two  pregnancies  in  the  district  is  carried.  About  one-third  of  the  births 
in  the  district  are  delivered  by  the  Out-Patient  Maternity  Service,  one-third 
by  midwives  and  one-third  by  private  doctors.  Private  doctors  send  many 
of  their  cases1  to  hospitals. 

The  nurses  urge  women  who  are  not  consulting  a  doctor  to  go  to  the 
prenatal  clinic.  They  also  send  to  the  clinic  private  physicians'  cases  with 
the  physicians'  consent,  and  patients  who  expect  to  have  midwives.  A  pre- 
natal clinic  is  conducted  twice  a  week  at  Health  Center  No.  8.  The  nurses 
try  to  visit  prenatal  cases  at  least  once  a  month,  and  when  possible  once  in 
three  weeks. 

The  cases  reported  to  the  Maternity  Hospital  Out-Patient  Service  still 
attend  the  clinic  and  are  cared  for  by  the  University  District  nurses.  If 
they  develop  abnormal  symptoms  they  are  turned  over  to  the  nurses  of  the 
Out-Patient  Service.  There  has  been  some  duplication  of  work  by  the  nurses 
of  these  two  organizations. 

Patients  are  referred  to  private  physicians  for  maternity  care,  if  able  to 
pay  the  fee  of  $50.00.  If  not,  they  are  referred  to  one  of  the  two  Out-Patient 
Maternity  Services.  Post-natal  care  is  given  by  the  Out-Patient  nurses.  As 
this  service  is  popular  there  is  not  much  maternity  service  left  for  the  nurse 
of  the  University  District.  This  is  a  disadvantage,  as  the  students  need 
adequate  practice  in  this  field.  On  the  other  hand,  the  University  District 
alone  has  as  many  pregnant  patients  under  supervision  as  there  are  under 
prenatal  care  in  all  the  other  districts  of  the  Division  of  Health  combined. 

School  Nursing 

No  school  nursing  is  done  by  the  University  District.  It  does  not  seem 
possible  for  the  present  staff  of  the  University  District  to  undertake  as  inten- 
sive work  in  the  parochial  schools  as  is  now  given  in  the  public  schools  by  the 
Board  of  Education.  The  students  get  their  education  in  this  branch  of 
work  under  the  Board  of  Education.  It  is  deemed  a  wise  decision  that  the 
University  District  should  not  undertake  school  nursing,  unless  the  number 
of  student  nurses  is  increased. 

Clinics 

No  tuberculosis  clinics  are  held  in  the  University  District.  It  is  hoped 
that  it  will  soon  be  possible  to  hold  such  clinics.  Prophylactic  baby  clinics 
are  held  three  times  and  prenatal  clinics  twice  a  week.  These  clinics  are  con- 
ducted for  all  purposes  except  medical  services,  by  the  instructors  of  the  Uni- 
versity District  for  the  purpose  of  giving  the  public  health  nurse  students 
experience  in  managing  clinics  and  familiarity  with  clinical  resources.  This 
experience  is  indeed  valuable  for  the  students,  but  it  puts  a  great  deal  of 
responsibility  upon  the  nurses  who  are  already  carrying  a  heavy  burden  as 


Nursing  795 

instructors  and  supervisors  of  the  districts.  One  instructor  spends  on  an 
average  eight  hours  per  week  in  her  clinic,  and  another  spends  an  average 
of  fifteen  hours,  in  addition  to  the  full  day  given  every  month  to  balancing 
the  milk  book  and  compiling  the  milk  report.  These  instructors  must  pre- 
pare for  the  clinic,  do  a  large  share  of  the  clerical  work  (volunteer  help  has 
not  been  satisfactory  and  paid  clerical  help  has  been  irregular),  teach  nurses 
who  are  on  duty  in  the  clinic  and  assume  the  entire  responsibility  of  its  man- 
agement and  success.     A  physician  is  in  attendance  at  each  clinic  session. 

In  order  not  to  have  the  burden  too  continuous,  rotation  has  been  arranged 
among  the  instructors,  but  this  does  not  lighten  the  volume  of  work.  It 
merely  changes  the  personnel.  If  the  high  standard  of  work  in  the  teaching 
district,  for  which  the  instructors  are  largely  responsible  is  to  be  kept  up 
they  should  not  be  required  to  give  thL  time  to  the  dispensaries.  In  order 
to  keep  this  service  under  the  University  District,  however,  a  special  instruc- 
tor for  the  dispensary  should  be  appointed.  This  will  in  any  case  be  neces- 
sary if  a  tuberculosis  clinic  is  opened.  Such  an  instructor  would  very  mate- 
rially relieve  the  pressure  on  the  other  supervisors  and  make  possible  the 
development  of  newer  principles  and  procedures  in  this  important  activity. 

Supervision 

The  object  of  supervision  in  public  health  nursing  is  to  detect  weaknesses 
and  develop  strength  in  the  nurses;  to  protect  the  patients;  to  prevent 
exploitation  of  the  nurses;  to  coordinate  and  utilize  to  the  best  advantage 
the  energies  of  the  staff. 

The  criticism  has  been  brought  against  the  University  District  that  it 
employs  too  many  instructors  or  supervisors.  This  question  received  earnest 
consideration,  but  evidences  of  over  supervision  though  carefully  sought, 
were  not  found. 

The  director  of  the  District,  in  accepting  the  responsibility  of  furnishing 
nursing  care  to  everyone  who  needs  it  within  this  District,  must  first  consider 
how,  with  a  constantly  changing  staff  of  nurses,  the  standard  of  nursing  can 
be  kept  consistently  high  and  uniform.  She  must  also  consider  how  the 
heavy  demands  for  nursing  can  best  be  met  without  exploitation  of  the 
nurses,  who  in  this  District  are  all  to  be  regarded  as  students  in  training. 

Ample  proof  was  given  that  the  character  of  the  supervision  is  excellent. 
This  excellence  was  shown  by  the  way  in  which  the  possibilities  of  nurses 
necessarily  of  different  calibre  were  developed.  Even  the  less  well  trained 
or  those  of  less  native  ability  showed  in  their  work  clear  evidences  of  good 
teaching.  It  is  probably  due  to  the  intensive  work  of  the  staff  of  instructors 
that  the  nursing  standards  of  the  University  District  have  been  high,  that  the 
patient's  interests  are  most  carefully  guarded  and  that  the  nurses  have  been 
fully  protected  from  too  much  work  in  the  field. 

General  Summary 

The  character  and  volume  of  the  work  in  the  University  District  prove 
that  a  nursing  program  which  is  almost  completely  generalized  except  for 


796  Hospital  and  Health  Survey 

school  nursing  can  be  carried  out  with  excellent  results.  No  branch  of  nurs- 
ing undertaken  has  suffered  from  its  merging  into  this  general  service.  An 
excellent  quality  of  service  is  given  in  all  types  of  disease.  Prenatal  nursing- 
is  more  vigorously  developed  than  in  any  other  district.  Care  of  tuberculous 
patients  and  sick  babies  is  as  thorough  and  constant  as  for  other  patients. 
It  should,  however,  be  said  that  visits  for  instruction  and  prevention  should 
be  more  frequent.  A  larger  number  of  students  would  make  this  possible. 
All  communk-able  diseases,  except  smallpox,  are  attended  and  preventive 
measures  are  emphasized.  In  fact,  the  work  throughout  is  painstaking, 
conscientious,  intelligent  and  of  high  quality. 

The  University  District  has  proved  also  that  it  is  possible  to  care  for  a 
district  satisfactorily  without  a  permanent  staff  other  than  the  instructors. 
It  has  been  shown  that  continuity  of  service  can  be  maintained  through  the 
instructors  and  that  the  students  are  capable  of  carrying  responsibility  for  a 
part  of  a  district  and  receiving  the  best  training  and  development  by  so  doing. 
The  supervision,  training  and  leadership  given  by  the  director  and  instructors 
is  of  the  highest  quality. 

It  is  evident,  however,  that  the  director  and  instructors  in  their  efforts 
to  be  fair  to  patients  and  nurses  alike  are  carrying  very  heavy  responsi- 
bility. The  method  of  remedying  this  has  not  revealed  itself  in  so  short  a 
study,  but  requires  careful  consideration.  In  spite  of  the  constant  burden 
of  work  there  is  a  cheerful  devotion  to  duty  that  reflects  itself  in  the  work  of 
the  nurses  in  the  field.  An  assistant  director  and  instructor  in  charge  of  the 
clinics  would  relieve  the  tension  appreciably. 

The  University  District  has  been  looked  upon  as  an  independent  labora- 
tory for  experimentation  in  policies  and  methods.  In  so  far  as  this  adds  to 
the  teaching  advantages,  it  is  sound  and  advisable.  Experiments  which 
might  jeopardize  or  injure  the  success  of  the  students'  experience  and  educa- 
tion should  be  tried  elsewhere. 

The  fact  that  the  district  is  a  teaching  district  and  that  the  work  must 
have  educational  value  has  always  been  recognized  and  kept  clearly  in 
mind.  For  this  reason  the  responsibility  for  the  field  work  has,  with  success, 
been  placed  directly  upon  the  students.  On  the  other  hand,  the  needs  and 
prerogatives  of  the  patients  have  never  been  minimized  or  lost  sight  of.  The 
educational  character  of  the  work  has  proved  to  be  to  the  patient's  benefit 
rather  than  detriment,  just  as  it  is  true  that  medical  attention  in  hospitals 
attached  to  medical  schools  is  usually  better  than  in  other  hospitals.  The 
students  are,  in  fact,  receiving  thorough  practice  in  public  health  nursing; 
the  patients  are  receiving  a  very  excellent  quality  of  nursing  service.  Close 
study  failed  to  disclose  any  indication  of  the  exploitation  of  either  group. 

RECOMMENDA  TIONS 

1.  That  the  director  be  provided  with  an  assistant  on  full  time. 

2.  That  an  additional  instructor  be  secured  to  take  charge  of  the  clinics. 

3.  That  the  number  of  students  who  can  be  accepted  be  increased. 


Nursing  797 


4.  That  the  University  District  continue  its  prenatal  nursing    and  undertake  post- 
natal nursing  as  a  part  of  the  city-wide  maternity  service. 

5.  That  instructive  and  preventive  work   among  sick  babies  and  tuberculous  patients 
be  developed  more  thoroughly. 


Prenatal  and  Maternity  Nursing  Service 

FROM  the  foregoing  accounts  of  public  health  nursing  in  Cleveland,  it  is 
evident  that  one  of  its  most  important  phases  is  the  least  coordinated, 
that  is,  the  nursing  provided  for  maternity  care,  including  prenatal, 
partum  and  postpartum  services.  Five  separate  agencies  are  at  present 
carrying  on  these  services,  in  whole  or  in  part  in  Cleveland.     These  are: 

Maternity  Hospital, 
St.  Luke's  Hospital, 
Mt.  Sinai  Hospital, 
University  District,  and  the 
Visiting  Nurse  Association. 

In  addition,  since  1918,  the  nursing  division  of  the  Division  of  Health  has 
been  charged  with  the  duty  of  prenatal  care,  but,  as  shown  in  the  report  of 
that  Division,  little  work  as  yet  has  been  done  along  this  line. 

In  the  report  of  the  Cleveland  Survey  on  Dispensaries  and  Hospitals, 
details  of  the  organization  and  of  the  medical  work  of  these  agencies  are 
given,  Part  X.  Here  we  are  concerned  only  with  the  character  of  the  nurs- 
ing services  needed  and  provided. 

As  we  have  seen,  a  consistent  effort  has  for  some  years,  with  a  large 
measure  of  success,  been  made  in  Cleveland  to  develop  the  system  of  general 
ized  nursing,  concentrated  under  as  few  agencies  as  possible.  It  is,  there- 
fore, high  time  to  plan  for  a  maternity  nursing  service  on  a  city-wide  plan, 
to  consider  how  it  may  best  be  organized  and  administered. 

Types  of  Patients 

In  any  comprehensive  plan,  various  types  of  patients  must  be  provided 
for.  Figures  are  available  to  show  the  total  number  of  births  registered  by 
type  of  delivery,  and  the  proportion  which  each  type  forms  of  the  total 
number  of  births  registered  for  the  year  1919,  viz:  19,123.  Grouped  by 
their  arrangements  for  confinement,  the  following  types  of  patients  need 
nursing  care : 

1 .  All  patients  who  are  to  be  confined  in  hospital  beds ;  accounting  in 
1919  for  4,980  registered  births,  or  25.5%  of  the  total. 

2.  All  patients  who  are  to  be  confined  by  out-patient  service;  account- 
ing in  1919  for  1,257  registered  births  or  6.5%  of  the  total. 


798  Hospital  and  Health  Survey 


3.  All  patients  who  are  to  be  confined  by  midwives;  accounting  in  1919 
for  5,903  registered  births,  or  30.8%  of  the  total. 

4.  Some  patients  who  are  to  be  confined  by  private  doctors  who  are 
not  giving  prenatal  care  and  consent  to  have  the  clinic  extend  such  care. 

5.  Some  patients  to  be  confined  by  private  doctors  for  whom  consulta- 
tion is  desired. 

The  cases  delivered  by  private  physicians,  both  in  institutions  and  in 
patients'  homes  of  whom  groups  4  and  5  form  a  large  part,  acccount  for  13,- 
196  births  registered,  or  69  per  cent  of  the  total  registered  births  for  the 
year  1919. 

Types  of  Nursing  Care  Needed 

For  the  first  group,  to  be  confined  in  the  hospital,  prenatal  care  in  the 
home  is  needed.  .    ■ 

For  the  second  group,  who  avail  themselves  of  out-patient  departments, 
nursing  care  is  necessary  in  addition,  during  the  confinement  and  post- 
partum period. 

For  the  third  group,  who  are  delivered  by  midwives,  prenatal  care  is 
needed. 

For  the  fourth  and  fifth  groups,  comprising  patients  of  private  doctors, 
the  three  types  of  care  are  needed. 

Moreover,  experience  proves  that  besides  adequate .  clinical  equipment, 
vigorous  continuous  propaganda  work  in  the  home  is  needed.  Without  it, 
few  take  advantage  of  the  clinic,  unless  in  need  of  free  services,  or  until  late 
in  pregnancy;  many  improvident  women,  relying  on  hospital  care  at  the 
last  moment,  never  go  to  the  clinic  or  have  any  prenatal  care;  midwife  cases, 
which  comprise  a  third  of  the  total  registered  births  in  Cleveland  in  1919, 
have  no  prenatal  care  at  all;  many  patients  engaging  a  private  doctor  during 
the  last  month  or  two  have  no  prenatal  care  or  medical  supervision. 

A  study  of  about  one  thousand  records  from  the  three  main  agencies 
giving  prenatal  care  and  with  available  statistics  (Western  Reserve  Univer- 
sity District  and  St.  Luke's)  showed  that  only  about  12  per  cent  of  all  these 
cases  had  prenatal  care  before  the  fifth  month,  while  62  per  cent  of  the  cases 
had  prenatal  care  during  the  last  three  months  of  pregnancy. 

Appropriate  Agencies  for  a  City  Service 

In  proposing  a  city-wide  plan  for  a  complete  prenatal  maternity  service, 
the  question  at  once  arises,  to  what  agent  or  agencies  it  should  be  entrusted. 
Obviously,  no  one  of  the  five  agencies  now  in  the  field  could,  with  its  present 
equipment,  take  over  so  large  an  added  responsibility.  Is  it,  then,  de- 
sirable to  create  a  new  agency  for  the  purpose,  or  to  propose  the  expansion 
of  one  of  those  already  taking  part  in  this  work?  And  if  so,  which  of  the 
present  agencies  is  best  fitted  for  such  an  expansion  on  the  basis  of  its  present 
methods  and  equipment? 


Nursing  799 

The  municipal  nursing  staff,  is,  as  we  have  seen,  greatly  overburdened, 
and  in  need  of  reorganization  in  the  assignment  of  work  and  supervision. 
The  Division  of  Nursing  is  at  present  grappling  with  the  problem  of  absorb- 
ing the  duties  with  which  it  has  been  newly  charged  each  year.  It  would, 
therefore,  be  inadvisable  at  this  time  to  propose  to  add  to  it  another  and  still 
larger  undertaking.  The  city  has  neither  funds  nor  facilities  at  this  time  to 
undertake  responsibility  for  obstetrical  and  postpartum  nursing  care.  More- 
over, the  city  might  not  succeed  in  reaching  patients  under  the  care  of  pri- 
vate doctors,  large  numbers  of  whom  have  only  moderate  incomes,  so  that 
they  cannot  afford  private  nurses  and  must  depend  upon  visiting  nursing 
care.  In  1919,  as  we  have  seen,  the  total  number  of  births  delivered  by 
private  doctors  numbered  69  per  cent  of  all  births  registered. 

Only  two  other  agencies  have  been  seriously  considered  for  city-wide 
maternity  nursing  service.  These  two  are  the  Maternity  Hospital  and  the 
Visiting  Nurse  Association. 

Maternity  Hospital 

The  proposal  to  extend  the  nursing  service  of  Maternity  Hospital  so  as  to 
offer  a  general  prenatal  and  maternity  service,  does  not  commend  itself  for 
various  strong  reasons.  It  would  indeed  appear  to  be  a  fundamental  mis- 
take. The  Maternity  Hospital  has  in  the  past  performed  a  valuable  service, 
such  as  is  the  function  of  a  University  hospital,  in  teaching  the  possibilities 
in  this  field  and  demonstrating  the  actual  saving  of  life  which  goes  with  a 
prenatal,  partum  and  post-partum  service. 

This  hospital  should  continue  to  be,  fundamentally  and  increasingly,  a 
training  field  for  nurses  as  well  as  for  medical  students,  i  n  the  obstetrical  • 
field.  To  attempt  to  extend  its  community  work  and  to  establish  a  city 
service,  instead  of  developing  and  extending  its  valuable  function  of  train- 
ing, would  be  to  miss  its  proper  office. 

Moreover,  the  nursing  service  of  a  hospital  by  its  nature  does  not  cover 
the  great  majority  of  registered  births,  that  is,  those  occurring  neither  in  the 
wards  nor  under  the  out-patient  department,  but  attended  in  their  homes 
by  private  physicians  or  midwives.  In  1919,  of  the  total  confinement  cases 
reported  in  Cleveland,  37.2  per  cent  were  delivered  by  physicians  in  the 
homes  of  private  patients,  and  30.8  per  cent  by  midwives  in  the  patients' 
homes,  or  an  estimated  total  of  babies  delivered  by  these  two  groups,  of 
13,000  or  68  per  cent. 

But  even  if  these  points  were  not  conclusive,  certain  weaknesses  in  the 
methods  of  work  as  at  present  carried  on,  would  in  a  larger  area  be  a  serious 
drawback  to  good  service.  The  nursing  care  of  this  hospital  is  character- 
ized by  a  lack  of  continuity  in  the  nursing  personnel  and  by  a  lack  of  the  best 
conceived  type  of  supervision  as  described  in  other  sections  of  this  report. 

Lack  of  Continuity 

The  lack  of  continuity  is  shown  by  the  division  of  the  work.  Details 
of  the  organization  of  the  Maternity  Hospital  clinics  are  given  in  the   Dis- 


800  Hospital  and  Health  Survey 

pensary  Report,  Part  X.     Here  the  chief  points  of  the  nursing  service  are 
described. 

The  prenatal  nurse,  with  headquarters  in  her  prenatal  station  calls  on 
the  patient  and  makes  observations  until  the  time  of  delivery.  The  patient 
is  then  turned  over  to  the  delivery  nurse  of  the  hospital,  who  is  taking  a 
special  course  in  obstetrics.  She  may  be  a  pupil  nurse,  or  she  may  be  a 
graduate.  She  accompanies  the  medical  student  for  delivery  in  the  case 
of  each  primipara,  in  all  other  cases  the  delivery  nurse  goes,  if  any  one  of 
them  is  available.  Thus  all  the  advantages  gained  by  the  prenatal  nurse 
from  knowing  the  patient  and  having  won  her  confidence  are  lost.  The 
post-partum  nurse  must  begin  the  acquaintance  over  again.  The  record 
system  is  not  such  as  to  give  the  help  which  might  be  given  in  keeping  up  the 
connection.  The  prenatal  records  appear  to  be  inadequate  in  scope  and 
poorly  kept. 

Lack  of  Supervision 
Prenatal  Care: 

For  prenatal  care,  four  full-time  graduate  nurses  are  employed.  They 
give  service  at  the  six  prenatal  clinics  now  operated,  and  spend  the  rest  of 
the  time  on  home  visits.  They  average  about  ten  calls  daily,  rising  in  some 
cases  to  fifteen  calls.  Where  districts  are  densely  settled  and  the  cases 
happen  to  be  so  grouped  that  transportation  does  not  require  much  waste 
of  time,  fifteen  instructive  visits  may  not  prove  to  be  impracticable,  but  in 
general  more  than  ten  prenatal  visits  a  day  will  be  found  to  result  in  sacri- 
fice of  thoroughness. 

Moreover,  though  all  patients  are  supposed  to  be  visited  every  two 
weeks,  and  acute  cases  daily,  it  was  stated  in  the  course  of  the  investigation 
that  these  visits  are  not  regular.  A  normal  case,  attending  the  clinic  regu- 
larly, may  be  seen  at  home  only  two  or  three  times  during  pregnancy.  The 
nurses  carry  in  their  bags  blood  pressure  apparatus  and  equipment  to  make 
urinalysis.  But  these  are  not  used  for  every  patient  visited,  as  the  best 
practice  requires.  Abnormal  cases  are  seen  daily  or  every  other  day  as  indi- 
cated. 

The  Director  of  Nurses  makes  an  effort  to  see  every  case  which  is  re- 
ported to  the  clinic,  but  not  necessarily  with  the  nurses.  Of  supervision  in 
the  field,  as  developed  for  graduate  nurse  staffs  in  the  best  public  health 
work,  and  essential  as  a  stimulus  as  well  as  a  guide,  there  is  here  none.  Any 
abnormal  cases  are  discussed  with  the  Director  of  Nurses.  Abnormalities 
found  in  home  visits  are  reported  verbally  to  the  Director,  who  enters  this 
information  on  the  prenatal  index  card,  made  out  when  each  new 
case  is  admitted;  but  there  is  no  detailed  weekly  or  monthly  report  kept 
by  the  nurse  as  a  record  of  her  own  performance.  There  is  no  system  by 
by  which  the  frequency  of  the  patient's  visit  to  the  dispensary  or  the  nurse's 
visit  to  the  home  is  automatically  checked  up. 

Delivery  and  Post-Partum  Care: 

This  care  is  given  by  the  student  nurses  under  supervision  of  the  assist- 
ant director.     Each  new  nurse  is  taken  into  her  district  by  the  assistant 


Nursing  801 

director,  but  for  only  half  a  day.     Thereafter,  the  assistant  director  drops  in 
on  her  daily  during  a  period  of  about  a  week. 

There  are  four  nurses  doing  post-partum  work,  each  averaging  about 
eight  cases  daily.  This  number  is,  again,  too  large  for  adequate  care  and 
instruction  in  the  home.  If  labor  occurs  during  the  day,  either  the  director 
or  the  assistant  director  makes  an  effort  to  get  into  the  home  before  the 
baby  is  delivered.  Each  newly  delivered  case  is  seen  by  the  assistant  di- 
rector the  day  after  the  confinement.  Oversight  of  the  patient's  condition 
is  thus  assured;  but  regular  supervision  of  the  nurses  who,  it  must  be  remem- 
bered, are  here  students-in-training,  is  not  accomplished. 

From  observation  of  five  post-partum~  cases,  it  was  evident  that  while 
the  essentials,  such  as  care  of  the  breasts,  external  irrigation,'  care  of  the 
baby,  etc.,  received  careful  attention,  the  work  was  not  up  to  the  nursing 
standards  observed  by  the  Visiting  Nurse  Association  or  in  the  University 
District.  Doubtless  the  unusually  large  number  of  cases  carried  by  the  Western 
Reserve  students  accounted  for  this  fact.  The  rooms  were  not  left  in  as  good 
order  as  desirable,  no  uniform  is  required,  one  nurse  being  observed  at  work 
in  a  chiffon  waist. 


Prenatal  and  Postnatal  Work  in  a  Generalized  Service 

In  contrast  to  the  specialized  work  of  the  Maternity  Hospital,  there  is 
available  in  Cleveland  the  example  of  an  agency  which  includes  prenatal 
work  in  a  generalized  nursing  service.  This  is  the  University  District, 
which  in  1919  had  442  dispensary  cases,  which  may  be  compared  with  485 
dispensary  records  studied  at  the  Maternity  out-patient  department.  The 
home  visits  of  the  University  District  nurses  upon  442  dispensary  cases 
numbered  1  391  or  3.1  per  cent  per  patient  as  against  271  visits  upon  483 
dispensary  cases  or  .6  per  cent  per  patient  by  the  Maternity  nurses.  In  the 
generalized  service,  therefore,  the  home  visits  recorded  were  5  times  greater 
in  number  than  in  the  specialized  service.  The  average  number  of  dispen- 
sary visits  per  patient  recorded  in  the  generalized  service  were  much  more 
numerous  than  in  the  specialized  (2.4  in  the  University  District  as  against 
1.5  at  Maternity). 

In  comparing  the  percentage  of  cases  reached  early  in  pregnancy,  the 
University  District  is  again  far  in  advance  according  to  the  records  studied, 
having  brought  almost  half  (46%)  of  its  total  cases  under  care  by  the  sixth 
month,  while  Maternity  had  only  19.2  per  cent  under  care  at  that  period 
of  pregnancy. 

It  seems  apparent  that  the  Maternity  hospital  records  studied  do  not 
truly  represent  the  quality  of  the  service  rendered  by  this  institution,  but  as 
the  permanent  records  of  any  service  should  be  available  as  a  basis  for  evalu- 
ation of  that  service,  the  results  of  this  study  of  records  are  given. 


802  Hospital  and  Health  Survey 


Records  of  No.  Dis- 

Dispensary  pensary     Aver-  No.  Home  Aver-  . 

Cases  Studied  Visits          age         Visits          age 

Maternity _ 483  708           1.5              271             .6 

University  District 442  1084          2.4            1391           3.1 

St.  Luke's _                141  No  record  of  home  or  dispensary  visits. 

Mt.  Sinai _ No  record  of  home  or  dispensary  visits. 

The  University  District  thus  in  a  small  district  and  with  a  high  ratio  of 
nurses  to  population  illustrates  the  possibility  of  including  prenatal  and 
postnatal  care  in  a  general  nursing  service  for  the  sick  which  gives  family 
care  and  instruction. 

While  it  is  true  that  fruitful  demonstrations  of  special  maternity  services 
have  been  made  in  other  cities,  nevertheless  an  extension  of  the  generalized 
nursing  service  for  the  sick  is  especially  appropriate,  since  Cleveland  has 
proved  its  ability  to  conduct  generalized  public  health  nursing  with  a  con- 
siderable measure  of  success,  as  well  as  a  true  generalized  nursing  service  in 
the  fields  of  sick  nursing  and  public  health  nursing  in  the  University  Dis- 
trict. 

The  Visiting  Nurse  Association 

In  the  Visiting  Xurse  Association  there  is  available  an  agency,  doing 
generalized  sick  nursing  in  homes  on  a  city-wide  plan,  with  adequate  and 
skilled  supervision,  which  already  makes  a  specialty  of  medical,  surgical 
and  maternity  nursing,— excellently  done  and  capable  of  further  expansion. 

This  Association  now  serves  all  groups  of  patients,  the  poor  and  those 
of  moderate  income,  midwife  and  private  doctor's  patients,  as  well  as  those 
intending  to  have  hospital  care. 

For  an  extended  program  to  provide  general  maternity  care,  this  Asso- 
ciation could  provide  service  by  a  graduate  nurse  trained  in  visiting  nursing, 
and  could  also  provide  supervision  for  student  nurses  if  necessary.  It  would 
afford  uniformity  and  continuity  of  service,  the  same  nurses  being  available 
for  all  three  types  of  care.  Because  of  its  large  staff,  small  districts,  and 
other  nursing  contacts,  it  could  greatly  increase  the  usefulness  and  adequacy 
of  the  clinics  through  the  early  discovery  of  pregnant  patients,  who  would 
be  urged  to  seek  medical  oversight  at  once,  at  the  clinics.  Such  patients 
would  also  receive  careful  prenatal  nursing  at  home  if  they  could  not  be 
persuaded  at  once  to  attend  a  clinic. 

For  these  reasons,  the  Visiting  Xurse  Association  appears  to  be  the  logical 
agency  in  Cleveland  to  which  the  extended  prenatal  and  maternity  services 
for  the  city  should  be  entrusted.  It  would  mean  a  large  expansion  for  this 
Association  entailing  large  expenditures,  and  responsibilities  with  which 
the  Association  is  well  fitted  to  cope.  Xo  greater  opportunity  to  serve  the 
community,  and  indeed  to  demonstrate  such  a  service  to  the  whole  country, 
could  be  offered. 

After  the  demonstration  had  been  made,  it  would  be  desirable  and  in 
line  with  past  policy  in  Cleveland  gradually  to  turn  over  this  service  to  the 


Nursing  803 

municipal  staff.  If  the  proposed  Extension  District  of  the  Division  of  Health 
is  established  as  is  suggested  elsewhere  (page  769)  for  the  extension  of  the 
municipal  nursing  work,  it  would  be  desirable  to  substitute  for  the  Visiting 
Nurse  Association  the  municipal  nurses  in  that  district,  except  for  attend- 
ance at  delivery. 

As  the  assumption  of  this  service  in  the  Extension  District  of^the  Di- 
vision of  Health  proves  practical  and  successful,  and  as  the  whole  nursing 
service  of  the  Division  of  Health  is  built  up  to  meet  its  present  activities, 
and  becomes  able  to  assume  new  functions,  the  service  might  be  turned 
over  district  by  district  to  the  Division  of  Health,  or  the  prenatal  service 
might  first  be  turned  over,  the  transfer  of  care  during  confinement  and  post- 
partum care  being  postponed. 

RECOMMENDA  TIONS 

It  is  therefore  recommended: 

1.  That  the  Visiting  Nurse  Association  give  prenatal  instruction  and  nursing  care 
in  the  homes,  reporting  findings  to  and  receiving  instruction  from  the  clinics  daily.  This 
service  could  be  provided  by  the  Visiting  Nurse  Association  as  a  uniform  service  to  all 
clinics. 

2.  That  clinics  be  maintained  under  the  proposed  Obstetrical  Council  to  serve  the 
entire  city  by  zones  or  districts  according  to  agreement  among  the  various  hospitals, 
nurses  for  service  within  the  clinics  to  be  provided  by  the  hospital  wherever  possible,  by 
the  Visiting  Nurse  Association  where  impossible. 

3.  That  nursing  care  during  confinement  be  provided  by  the  Visiting  Nurse  Associa- 
tion (a  continuous  graduate  staff  for  deliveries  to  be  provided  by  the  Visiting  Nurse  Asso- 
ciation for  this  purpose),  or  by  students  of  the  hospitals  under  the  supervision  of  the 
Visiting  Nurse  Association. 

4.  That  post-partum  nursing  be  provided  by  the  Visiting  Nurse  Association  for  all 
clinics,  or  by  student  nurses  under  the  Visiting  Nurse  Association. 

5.  That  in  the  University  District,  for  the  Visiting  Nurse  Association,  the  university 
staff  be  substituted,  except  for  attendance  at  delivery.  That  in  the  proposed  Exten- 
sion District  of  the  Division  of  Health  the  Visiting  Nurse  Association  be  replaced  by  the 
municipal  nurses,  except  for  attendance  at  delivery. 

6.  That  a  uniform  procedure  be  established  for  all  districts  and  observed  by  all  staffs. 

7.  That  if  the  proposed  Obstetrical  Council  is  formed,  a  sub-committee  on  prenatal 
and  maternity  nursing  from  the  Central  Committee  act  as  the  sub-committee  on  nursing 
of  the  Obstetrical  Council,  and  that  the  Central  Committee  be  represented  on  the  Ob- 
stetrical Council  and  vice  versa. 

Industrial  Nursing 

THE  Survey  of  Industrial  Hygiene  in  Cleveland  has  shown  that  there 
were,  at  the  time  of  the  investigation,  seven  full-time  industrial  phy- 
sicians and   104   industrial  and   mercantile  nurses.     In   36  plants,   66 
nurses  were  working  with  part-time  physicians. 

These  figures  indicate  clearly  enough  the  responsibilities  of  the  nurse  in 
industry,  and  the  possibilities  which  lie  before  her  in  her  contact  with  the 


804  Hospital  and  Health  Survey 

large  bodies  of  men  and  women  who  are  congregated  in  industrial  establish- 
ments. 

Obviously,  no  hard  and  fast  rules  can  apply  to  all  types  of  industrial 
nursing;  it  must  vary  with  conditions,  with  the  size  of  plants,  the  type  of 
management  and  of  employe,  etc.  But  under  all  these  differences  and  with 
all  the  varied  duties  which  the  industrial  nurse  may  legitimately  perform, 
there  should  be  one  essential  aim,  common  to  all  good  public  health  nursing, 
that  is,  the  maintenance  of  health  and  the  teaching  of  hygienic  habits. 

With  so  wide  a  field  before  her  and  in  a  branch  of  public  health  work  so 
new  and  unstandardized,  it  is  not  surprising  that  the  industrial  nurse  has  as 
yet,  broadly  speaking,  scarcely  found  herself.  She  stands  too  often  between 
the  industrial  physician,  who  for  the  most  part  regards  her  as  a  mere  adjunct 
to  the  surgical  dispensary,  and  the  employer  or  his  representative,  in  whose 
mind  she  is  vaguely  to  function  in  creating  better  industrial  relations  in  his 
plant. 

The  danger,  therefore,  is  that  industrial  nursing  will  be  diverted  on  the 
one  hand  into  pure  dispensary  assistance,  or  on  the  other,  into  pure  welfare 
work.  In  neither  of  these,  though  both  may  be  part  of  her  duties,  lies  the 
sole  function  of  the  industrial  nurse.  On  her  training  and  personality  it 
will  in  many  instances  depend  whether  she  develops  a  constructive  type  of 
work,  enlisting  the  management's  and  workers'  cooperation,  or  is  submerged 
in  the  routine  of  first  aid  or  of  factory  housekeeping  or  recreational  activities. 

The  Nursing  Survey  made  a  detailed  study  of  twelve  representative  in- 
dustrial nurses  in  Cleveland  to  observe  their  work,  the  types  of  duties  per- 
formed by  them  and  the  emphasis  on  prevention  of  illness  and  of  accidents 
as  well  as  on  treatment.  The  establishments  visited  included  metal  working 
plants,  food  and  clothing  factories,  public  utilities,  and  department  stores. 
Three  of  these  plants  had  full-time  physicians,  the  others  had  either  a  part- 
time  or  no  physician. 

Work  Confined  to  First  Aid 

Several  of  the  nurses  observed  were  confined  in  their  activities  wholly  to 
the  first  aid  room;  they  were  strictly  dispensary  nurses  with  no  thought  of 
responsibility  beyond  dressing  injuries  and  no  encouragement  on  the  part 
of  the  management  to  expand  their  interests.  The  limitations  of  this  type 
of  work  were  well  illustrated  by  one  of  these  nurses  whose  business-like  dis- 
patch enabled  her  to  handle  quickly  and  efficiently  the  large  number  of  cases 
passing  through  the  dispensary,  but  whose  lack  of  interest  and  coldness  re- 
pelled any  further  advances  on  the  part  of  the  girl  employes  in  illness  or 
trouble. 

In  contrast  to  this  nurse  was  an  older  woman,  also  of  the  dispensary 
type  and  less  well  equipped  technically,  but  of  warm  human  sympathies  who 
had  gained  the  confidence  of  a  large  body  of  workmen  in  another  plant 
through  the  contacts  made  in  the  first  aid  room. 

An  extreme  instance  of  failure  to  connect  first  aid  work  with  prevention 
of  injuries  was  observed  in  another  plant  where  a  man  was  treated  three 
times  in  one  day  by  a  nurse  for  cutting  his  hand  at  the  same  machine.     Here 


Nursing  805 

the  nurse  was  not  allowed  to  leave  the  dispensary.  She  was  regarded  by 
the  management,  and  had  learned  to  regard  herself,  as  a  permanent 
fixture  of  the  first  aid  room,  a  mere  mechanical  agent  for  binding  up  cuts  or 
wounds. 

Work  Outside  the  Dispensary 

Ranging  upward  from  this  most  limited  performance,  there  were  ob- 
served in  Ceveland  many  varieties  of  work  and  of  responsibility  carried  by 
the  industrial  nurse.  In  some  plants  the  nurse  had  in  charge,  under  the 
standing  orders  of  the  attending  doctor,  the  entire  first  aid  and  emergency 
treatment,  and  was  responsible  for  all  records,  follow-up,  re-dressings,  etc. 
In  one  such  establishment  the  nurse  made  a  rule  of  having  the  doctor,  in 
his  daily  visit,  see  all  new  cases  and  all  infections. 

Procedures  naturally  differ  as  to  the  nurse's  responsibility  for  such  mat- 
ters as  plant  sanitation  and  the  safety  of  employes.  While  supervision  of 
these  matters  is,  in  large  plants,  in  the  hands  of  specialists,  in  smaller  fac- 
tories such  supervision  was  found  to  be  a  valuable  part  of  the  nurse's  work, 
especially  when  combined  with  instruction  of  the  employes  in  matters  of 
sanitary  equipment  and  safety. 

Sharing  in  Prevention  of  Accidents 

In  contrast  to  the  dispensary  nurse  and  the  repetition  of  cuts  cited  above, 
other  nurses  in  Cleveland  were  taking  part  in  the  prevention  as  well  as  cure 
of  accidents.  One  nurse  regularly  inspected  the  scene  of  accidents.  While 
this  might  lead  her  beyond  her  field,  when  technical  knowledge  of  machinery 
was  needed,  yet  she  had  been  able  to  point  out  obvious,  overlooked  causes 
of  accidents  such  as  bad  lighting  or  the  presence  of  an  obstruction  in  the 
way  of  the  employes. 

The  industrial  nurse  should  have  sufficient  knowledge  of  the  technical 
processes  used  in  her  plant  to  know  and  advise  on  the  safeguards  provided. 
Yet  she  is  often  totally  uninstructed  in  such  matters.  On  one  occasion  in 
Cleveland  the  nurse  was  found  wholly  ignorant  of  certain  types  of  respirators 
provided  for  a  certain  process  and  hence  incapable  of  advising  the  workers 
with  regard  to  using  them. 

Sharing  in  Prevention  of  Disease 

Constructive  health  work  and  ability  to  gain  the  workers'  confidence  so 
that  they  will  consult  her  in  matters  of  ill-health,  incipient  as  well  as  acute, 
should  clearly  be  the  center  of  the  industrial  nurse's  business.  The  other 
aspects  of  her  work-first  aid,  safety,  sanitation  and  welfare  work — should 
all  be  directed  to  this  general  end.  The  aim  of  maintaining  health  and 
educating  the  workers — men  and  women  alike — in  matters  of  health  should, 
indeed,  distinguish  the  industrial  nurse  from  other  types  of  welfare  workers. 
Individual  instances  of  good  work  along  these  lines  were  observed  in  Cleve- 
land, but  as  elsewhere,  it  was  on  the  whole  slighted  and  too  often  ignored  in 
the  multiplicity  of  other  duties. 

In  many  plants  the  nurse  spends  far  too  much  time  on  recreational  and 
welfare  activities.     Absorption  in  these  is  as  alien  to  constructive  health 


806  Hospital,  and  Health  Survey 

work  as  absorption  in  surgical  routine.  In  one  establishment  the  nurse 
devoted  two  evenings  a  week  to  social  meetings,  while  failing  to  note  obvious 
health  hazards  in  certain  rooms  and  making  no  effort  to  educate  the  girls  by 
talks  on  health  either  individually  or  in  groups. 

The  transfer  of  workers  from  jobs  for  which  they  are  physically  unfit  to 
other  positions  better  suited  to  their  physiques  is  a  genuine  health  measure 
which  nurses  may  well  recommend  to  the  management.  Such  transfers  had 
been  successfully  recommended  by  nurses  in  Cleveland  for  various  cases  of 
flat-foot  and  varicose  veins.  Some  girls  affected  by  a  necessarily  cold  work- 
room and  others  who  were  suffering  from  dermatitis  had  been  benefited  by 
a  change.  These  isolated  examples  show  how  great  an  influence  the  nurse 
may  have  in  prevention  of  the  illness  before  it  becomes  acute,  if  she  is  per- 
sonally familiar  with  the  workers  and  on  terms  of  confidence  with  them. 

Education  in  hygienic  habits  is  also  clearly  one  of  the  nurse's  first  duties, 
as  yet  little  developed.  One  nurse  had  recently  regained  a  valuable  girl 
worker  and  had  lessened  her  susceptibility  to  constant  colds,  by  persuading 
her  to  give  up  chiffon  waists  in  winter-time  and  to  dress  more  warmly. 
Another  nurse  encouraged  hygienic  habits  in  a  good  factory  by  making 
daily  inspections,  providing  clean  caps  and  aprons  and  urging  personal 
cleanliness.  In  one  room  unaffected  by  the  artificial  ventilation,  she  had 
arranged  to  have  the  windows  opened  ten  minutes,  morning  and  afternoon. 

Another  example  of  good  preventive  work,  along  a  somewhat  different 
line,  was  the  nurse's  successful  insistence  upon  installation  of  a  sterilizer  in 
the  lunch-room  of  a  plant  in  which  employes  known  to  be  suffering  from 
tuberculosis  and  venereal  disease  were  in  contact  with  the  other  workers. 

Some  Causes  of  Failure 

Too  often,  however,  instead  of  trying  to  teach  hygienic  habits  the  nurse 
relies  merely  upon  giving  drugs.  Contrary  to  all  good  medical  and  nursing 
practice,  nurses  were  found  habitually  giving  sedatives  and  medication  for 
many  minor  ailments.  This  widespread  practice  should  be  abandoned  at 
once. 

Another  serious  fault  in  industrial  nursing  in  Cleveland,  which  it  shares 
with  industrial  medical  practice,  is  the  lack  of  records  and  statistics.  In 
many  cases  neither  the  management  nor  the  industrial  physician  encourages 
or  indeed  takes  any  interest  in  the  nurse's  reports.  Yet  without  reports  and 
records,  the  nurse  cannot  gauge  her  own  progress  or  be  in  a  position  to  prove 
her  points  to  her  superiors.  A  simple  and  effective  system  of  records,  adapted 
as  necessary  to  the  conditions  of  individual  plants,  and  showing  so  far  as 
possible  the  relation  of  nursing  care  to  such  matters  as  compensation  claims, 
statistics  of  accidents,  illness  and  absence  of  employes,  is  one  of  the  most 
urgent  needs  of  industrial  nursing  in  Cleveland.  Provision  of  lay  assistants 
in  record  keeping  as  well  as  in  the  dispensary  is  greatly  needed  and  would 
release  the  nurse  for  her  more  important  duties. 

Lay  assistants  are  desirable  also  for  all  routine  following  up  of  absentees. 
In  all  cases  of  illness,  too  little  emphasis' on  home  visiting  was  found  in  Cleve- 
land.    This  lack  is  unfortunate  since  a  knowledge  of  home  conditions  and 


Nursing  807 

good  contacts  in  the  home  are  of  first  importance  in  obtaining  the  genuine 
confidence  of  the  workers.  The  services  of  the  Visiting  Nurse  Association 
of  Cleveland  should  be  called  on  for  bedside  care  if  necessary,  after  perhaps 
one  or  two  visits  by  the  industrial  nurse. 

The  isolation  of  the  industrial  nurse  keeps  her  from  contact  with  the 
rapid  developments  of  public  health  nursing  and  of  industrial  hygiene,  with 
which  she  should  be  acquainted  and  in  which  she  should  share.  Few  indus- 
trial nurses  have  had  adequate  training  for  their  special  field,  most  have  at 
best  learned  through  their  own  experiences  and  their  native  abilities.  In 
cities  in  which  industrial  nurses  are  a  part  of  some  agency,  such  as  the 
Visiting  Nurse  Association,  they,  like  the  rest  of  the  staff,  benefit  from 
belonging  to  such  an  organization  and  sharing  its  general  standards  and 
practices. 

The  Nursing  Survey  has  recommended  the  inclusion  on  the  Central 
Nursing  Committee  of  a  representative  of  industrial  nursing.  The  Industrial 
Nurses'  Club  might  be  of  much  more  technical  professional  value  to  nurses 
than  it  has  been  in  the  past,  and  either  it,  or  some  similar  organization, 
should  be  actively  organized.  It  should  be  a  real  center  for  developing  this 
most  recent,  and  one  of  the  most  important,  branches  of  public  health  nurs- 
ing as  it  is  capable  of  being  developed  in  industry. 

A  discussion  of  Industrial  Nursing  also  appears  in  the  chapter  on  Indus- 
trial Medical  Service,  Part  VII. 


808  Hospital  and  Health  Survey 

Some  Notes  on  Private  Duty  Nursing 

Unnecessary  Employment  of  Full-Time  Graduate  Nurses 

IT  is  often  asserted  both  by  physicians  and  by  trained  nurses  that  in 
many  cases  of  minor  illness  or  of  convalescence,  the  services  of  a  graduate 
nurse  are  unnecessary  and  that  such  cases  can  be  adequately  cared  for 
by  less  highly  trained  persons,  or  indeed  by  members  of  the  family. 

With  the  object  of  obtaining  some  more  concrete  information  as  to  such 
possible  substitution,  a  brief  inquiry  was  addressed  to  a  small  group  of 
private  duty  nurses  in  Cleveland.  The  number  of  cases  reported  on  is  too 
small  to  be  at  all  conclusive,  but  the  replies  received  are  suggestive  and  in- 
dicate that  a  wider  investigation  might  yield  valuable  conclusions. 

Inquiries  were  addressed  to  25  nurses.  They  were  asked  whether,  dur- 
ing the  past  year,  any  of  their  patients  could  have  dispensed  with  the  care  of 
a  full-time  graduate  nurse,  either  altogether  or  for  part  of  the  time.  Replies 
were  received  from  15  nurses.  They  were  also  asked  which  if  any  of  the  fol- 
lowing substitutes  could  have  replaced  the  graduate  nurses,  viz:  a  so-called 
"practical"  nurse,  members  of  the  patient's  family  or  an  "hourly"  nurse, 
that  is,  a  graduate  nurse  engaged  for  an  hour  or  two  per  day. 

Use  of  Hourly  Nurse  Recommended 
Of  275  cases  nursed  during  the  period  reported  on,  68  or  a  quarter  (24.7%) 
might,  in  the  opinion  of  the  nurses,  have  done  without  their  services  for  all 
or  part  of  the  illness. 

The  outstanding  fact  which  emerges  from  this  brief  inquiry  is  the  agree- 
ment among  the  nurses  that  of  the  46  patients  who  could  have  dispensed 
with  their  services  for  part  of  the  time,  34  or  almost  three-quarters  (73.9%) 
could  have  been  cared  for  by  hourly  nurses.  This  estimate  is  no  doubt 
in  part  due  to  the  large  number  of  acute  surgical  cases  represented  in  the 
total  group.  For  in  such  cases  expert  continuous  nursing  may  obviously  be 
needed  for  only  a  short  time,  after  which  an  hour  or  two  per  day  might  readily 
suffice  for  the  necessary  daily  nursing  care. 

Nature  of  Cases 

Of  the  total  number  of  cases  reported,  about  three  out  of  five  were  hos- 
pital cases,  and  of  these  almost  all  were  surgical.  The  remaining  two- 
fifths,  mainly  medical  cases,  were  nursed  at  their  homes.  Only  about  one 
in  nine  of  the  home  patients  was  surgical. 

Acute  cases  reported  upon  far  outnumbered  chronic  cases,  both  at  home 
and  at  the  hospitals.  The  proportion  of  acute  to  chronic  cases  at  home  was 
95  to  9,  and  in  hospitals  it  was  159  to  12. 

Two  of  the  nurses  stated  that  they  did  not  take  any  except  acute  cases. 
The  inclusion  of  the  reports  of  these  nurses  makes  the  proportion  of  cases 
which  could  have  been  cared  for  without  graduate  nursing  care  less  than  it 
would  ordinarily  be. 

Number  of  Nurses  Reporting  Unnecessary  Employment 
Thirteen  out  of  the  fifteen  nurses  reported  that  they  had  been  unneces- 
sarily employed  at  some  time  during  the  period  reported  on.     (For  various 


Nursing  809 

personal  reasons  the  period  reported  on  varied  from  four  to  seventeen  months, 
the  average  being  somewhat  over  ten) .  The  two  nurses  not  having  had  such 
cases  were  among  the  four  reporting  on  a  very  short  period,  viz :  from  four  to 
six  months  only. 

Amount  of  Unnecessary  Employment 

As  has  been  stated,  in  68  of  the  275  cases  reported  on,  the  graduate  full- 
time  nurse  might  have  been  otherwise  replaced.  Omitting  one  nurse  whose 
service  consisted  of  an  exceptionally  rapid  succession  of  acute  cases,  the 
total  number  of  cases  of  unnecessary  employment  amounted  to  67  out  of  226, 
or  29.6%,  which  is  more  nearly  representative  of  the  group.  In  individual 
reports  the  percentage  of  cases  of  unnecessary  employment  varies  greatly, 
ranging  from  72.7%  of  all  cases  cared  for  by  a  nurse  in  the  period  in  ques- 
tion, down  to  2%  of  all  cases,  the  median  being  44.4%.  In  other  words,  one 
nurse  had  11  such  cases  out  of  20  cases  in  all;  another  had  8  out  of  11;  the 
lowest  proportion  being  1  out  of  49. 

Similarly,  the  length  of  time  spent  in  unnecessary  employment  by  the 
15  nurses  varied  greatly.  No  definite  statement  can  be  made  on  this  point, 
as  information  was  sometimes  lacking  and  sometimes  uncertain.  One 
nurse  reported  as  much  as  three  months'  unnecessary  nursing  in  a  year's 
experience,  or  25%  of  her  total  time;  another  4  months  out  of  11M>  months 
or  34.8%.  The  average  length  of  time  so  spent  for  10  nurses  who  were 
able  to  give  an  estimate,  amounted  to  something  over  Vy^  months  per  nurse 
per  annum. 

Possible  Substitutes  for  Full-Time  Graduate  Nurse 
Of  the  sixty-eight  cases  on  which  these  graduate  nurses  reported  un- 
necessary employment,  about  one-third  could  have  been  cared  for  by  some 
other  arrangement  during  their  entire  illness.  In  fourteen  of  these  cases  a 
practical  nurse,  in  seven  cases  a  member  of  the  family,  and  in  one  case  an 
hourly  nurse,  would  have  sufficed. 

The  remaining  two-thirds  (46)  could  have  dispensed  with  the  full-time 
graduate  nurse's  services  during  a  part  of  their  illness  only.  As  has  already 
been  stated,  in  thirty-four  cases,  she  could  have  been  replaced  by  hourly 
nursing.  In  seven,  it  is  believed  that  a  practical  nurse  would  have  sufficed, 
and  a  member  of  the  family  in  the  remaining  five  cases. 

Thus,  in  the  opinion  of  the  15  nurses  consulted,  the  cases  cared  for  dur- 
ing the  given  period  were  divided  as  follows: 

(a)  A  large  proportion  of  cases  in  which  hourly  nurses  could  have  relieved  the  full- 
time  nurses  after  the  most  serious  stage  was  passed,  and  one  case  which  could  have  been 
entirely  cared  for  in  this  way. 

(b)  A  considerable  proportion  of  cases  which  could  have  used  a  practical  nurse  dur- 
ing the  entire  sickness,  and  a  few  in  which  such  nursing  could  have  been  utilized  for  part 
of  the  duration  of  the  case  only. 

(c)  A  few  patients  who  could  have  been  nursed  during  their  entire  illness  and  a  few 
during  part  of  their  illness  by  members  of  their  own  families. 

EMPLOYMENT  OF  TRAINED  ATTENDANTS 

In  Cleveland  as  elsewhere  the  employment  of  trained  attendants  has 
been  a  subject  of  controversy.     On  the  one  hand  there   is   undoubted   need 


810  Hospital  and  Health  Survey 

of  persons  capable  of  rendering  personal  service  and  some  small  degree  of 
nursing  care  to  those  who  are  ill  but  who  do  not  need  the  services  of  a  grad- 
uate nurse.  The  present  shortage  of  nurses  for  bedside  care  emphasizes  the 
desirability  of  making  available  the  services  of  such  a  class  of  workers,  in 
order  to  release  the  graduate  nurses  for  duties  which  they  alone  can  compass. 

Our  brief  inquiry  into  possible  substitutes  for  the  full-time  graduate 
nurse  shows  jthat  in  the  opinion  of  these  private  duty  nurses  themselves,  a 
part  of  their  cases  might  have  been  carried  by  attendants  or  "practical" 
nurses  as  well  as  by  "hourly"  nurses. 

The  Nursing  Survey  recognizes  the  value  and  need  of  the  trained  at- 
tendant. It  has  been  urged  to  formulate  an  educational  plan  and  short 
courses  for  the  training  of  such  workers.  But  to  this  plan  there  appear  to 
be  at  present  several  valid  objections.  For  it  must  be  recognized  that  the 
employment  of  the  trained  attendant  brings  with  it  unmistakable  dangers, 
especially  when,  unequipped,  she  assumes  the  part  of  the  fully  trained 
nurse.     Against  this  danger  the  patient  must  in  some  way  be  protected. 

The  experience  of  the  Visiting  Nurse  Association  of  Cleveland,  in  dis- 
continuing its  attendant  service  after  almost  three  years'  trial,  appears  so 
far  as  it  went,  to  have  been  conclusive.  The  failure  was  due  to  causes  oper- 
ative elsewhere  as  well  as  in  Cleveland,  that,  is  to  the  difficulties  of  retaining 
control  of  the  work  and  the  charges  of  the  attendants,  while  responsible  for 
their  employment. 

That  the  pay  of  trained  attendants  can  be  very  much  lower  than  that  of 
the  graduate  nurses,  it  is  probably  unreasonable  to  expect,  since  their  cost 
of  living  is  not  materially  less  than  that  of  the  graduate  nurses.  That  there 
is  a  genuine  demand  for  the  trained  attendant  in  her  own  sphere,  the  experi- 
ence of  the  Visiting  Nurse  Association  has  amply  demonstrated  anew. 

The  question  at  once  arises  whether  safeguards  cannot  be  devised  to  re- 
tain the  benefits  and  minimize  the  dangers  of  such  a  service.  From  experi- 
ence in  other  lines  of  work  it  would  appear  that  no  better  safeguard  has 
been  devised  than  through  legislation  defining  the  status  of,  and  licensing, 
both  graduate  nurses  and  those  trained  to  give  services  of  a  different  but 
no  less  necessary  order. 

A  precedent  for  such  legislation  already  exists  in  many  states  but  not 
yet  in  Ohio,  in  the  laws  licensing  the  practice  of  dental  hygienists  (Connecti- 
cut, New  York;  Massachusetts)  that  is,  of  persons  authorized  to  practise 
dental  cleansing  without  use  of  instruments  and  only  under  the  supervision 
of  a  licensed  dentist.  Here  there  has  been  established  successfully  the 
licensing  of  two  different  grades  of  workers,  for  different  grades  of  service 
in  the  same  profession.  Penalties  for  fraud,  or  for  practising  under  any  but 
the  appropriate  name,  should  obviously  be  provided  for  in  such  legislation. 

At  the  present  time,  and  until  the  necessary  regulation  by  city  or  state 
ordinance,  has  been  enacted,  it  does  not  appear  desirable  to  recommend  the 
establishment  of  courses  for  further  training  of  attendants  in  Cleveland. 
The  framing  and  enactment  of  suitable  legislation  should  take  first  place, 
in  plans  for  action  in  this  matter. 


THE  CLEVELAND  HOSPITAL  AND  HEALTHgSURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

TV.  Tuberculosis. 

V.  Venereal  Disease. 

VI.  Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing 

X.     Hospitals  and  Dispensaries. 

XL     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 

The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 

THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Premier  Press 

Cleveland,  O. 


Hospitals    and 
Dispensaries 


Part  Ten 


Cleveland     Hospital     and 
Health     Survey 


Copyright,  1920 

by 
The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 
308  Anis  field  Bldg. 
Cleveland    •  Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  for  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 
Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators : 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 
Josephine  Goldmark,  B.  A.,  Director  of  the  Nursing  Survey; 
Wade  Wright,  M.  D.,  Director  of  the  Industrial  Hygiene  Survey; 
Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 
S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 

and  Maternity  Survey; 
T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 
W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 
Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  Welfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland 
Hospital  Council.  A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


-  -  :■    vi 


■    -  '• .  /-'■■ 


TABLE  OF  CONTENTS 

I.  The  Care  of  the  Sick —  paQe 

Resources  for  Care gjg 

Some  Definitions §22 

II.  Hospitals — 

Hospital  Provisions  and  Community  Needs 828 

Organization  for  Service 838 

The  Human  Problem  of  the  Hospital  Patient 849 

The  Medical  Profession  and  the  Hospitals 858 

Finances  and  Administration 868 

Some  Practical  Matters  of  Administration 877 

III.  Dispensaries — 

Dispensaries  in  Cleveland 890 

The  Public  Health  Dispensaries 901 

Policies  and  Needs g^2 

The  Down-town  Dispensary ,  922 

IV.  Special  Problems — 

The  Convalescent  and  the  Hospital 926 

Community  Program  for  Convalescent  Care._ 938 

Chronic  Illness  and  Its  Care 944 

Social  Service  in  Hospitals  and  Dispensaries 952 

The  Ambulance  Service  of  Cleveland 961 

V.  Hospital  and  Dispensary  Planning — 

Community  Planning qqq 

Individual  Hospital  Planning 973 

Organization  to  Carry  Out  Plans 979 

Appendix — 

Tables...  984 


Hospitals    and   Dispensaries 

By  Michael  M.  Davis,  Jr.,  Ph.  D. 

I.      Tne  Care  01  the  Sick 
RESOURCES  FOR  CARE 

NO  thorough  understanding  of  the  work  and  problems  of  the  hospitals 
and  dispensaries  of  Cleveland  can  be  had  without  seeing  these  institu- 
tions in  a  broad  perspective.  The  primary  purpose  which  leads  to 
the  establishment  of  hospitals  and  dispensaries  is  to  provide  care  in  illness. 
We  need  to  understand  not  only  what  hospitals  and  dispensaries  do  for  their 
patients,  but  also  their  relations  to  the  community,  and  the  part  which  they 
should  play  in  the  life  of  the  average  family.    ■ 

The  volumes  of  the  Cleveland  Hospital  and  Health  Survey  which  precede 
this,  in  the  Survey's  series  of  publications,  have  been  devoted  to  general  com- 
munity problems  and  to  public  health  programs.  As  Dr.  Haven  Emerson, 
Director  of  the  Survey,  says:  "First  comes  the  description  of  the  environ- 
ment of  the  community;  then  its  efforts  at  self -protection  against  disease. 
Then  we  must  logically  put  education  before  practice;  and,  as  the  climax  of 
the  whole,  the  most  elaborate,  the  most  intricate,  the  most  difficult  of  all 
medical  social  undertakings,  the  Hospital  and  the  Dispensary,  to  show  how 
a  community  does  or  can  take  care  of  those  whom  it  has  failed  to  protect." 

The  great  emergencies  which  strike  the  life  of  the  average  family  are  sick- 
ness, accident,  and  unemployment.  Sickness  and  accident  both  affect  the 
physical  welfare  of  the  body,  varying  from  the  most  trivial  illness  to  the 
gravest  emergency.  The  resources  for  dealing  with  sickness  and  accident 
vary  accordingly,  from  the  application  of  the  simplest  home  remedies  to 
the  tense  dramas  of  the  operating  table. 

Studies  of  sickness  made  by  the  Metropolitan  Life  Insurance  Company 
among  its  industrial  policy  holders,  and  by  other  agencies,  indicate  that  from 
two  to  three  per  cent,  of  the  population  of  a  city  like  Cleveland  are  usually 
sick  at  any  one  time.  This  excludes  minor  illness  and  diseases  not  causing 
incapacity.  In  greater  Cleveland  this  means  that  20,000  to  30,000  persons 
are  usually  to  be  found  ill  on  any  given  day,  the  number  of  course  showing  a 
wide  variation  according  to  season  and  to  other  conditions  like  the  wide- 
spread presence  of  epidemic  disease.  We  know  that  the  hospital  popula- 
tion of  Cleveland  ranges  from  2,000  to  3,000,  being  generally  near  2,500. 
Thus  about  ten  per  cent,  of  the  sickness  in  Cleveland,  excluding  "minor" 
ailments,  is  generally  cared  for  in  hospitals.  These  figures  should  help  to 
put  the  hospital  problem  in  its  due  perspective. 

*  The  section  of  this  report  entitled  "Some  Practical  Matters  of  Administration,"  is  by  Warren 
L.  Babcock,  M.  D.,  Consultant  in  Hospital  Administration  for  the  Survey.  Other  contributions  by 
Dr.  Babcock  are  indicated  in  their  places,  and  his  helpful  cooperation  throughout  is  gratefully  acknowledged. 
Mrs.  Mary  Strong  Burns,  R.  N.,  is  the  author  of  the  section  on  "The  Convalescent  and  the  Hospital," 
and  Frederic  Brush,  M.  £>.,  of  an  important  part  of  "Community  Program  for  Convalescent  Care." 
For  the  collection  of  much  information  utilized  in  the  report  the  author  is  indebted  to  many  of  his  col- 
leagues in  other  branches  of  the  Survey.  Especial  acknowledgment  should  be  made  of  the  studies  con- 
tributed by  Anna  M.  Richardson,  M.  D.,  and  by  Miss  Harriet  L.  Leete,  R.  N.;  and  of  the  devoted,  pains- 
taking work  of  Miss  Josephine  Colegrove  in  the  collation  of  data  and  the  preparation  of  the  manuscript 
for  the  printer. 


82t)  Hospital  and  Health  Survey 


We  need  to  approach  the  study  of  the  hospitals  and  dispensaries  of  a 
great  city  from  the  standpoint  of  the  community  rather  than  of  the  institu- 
tion; to  see  them  as  the  average  citizen  and  the  average  family  sees  them, 
rather  than  as  the  physician  or  the  specialist  in  hospital  administration. 
Laying  aside  for  the  moment  the  demands  which  the  average  family  may 
make  on  hospitals  and  dispensaries  for  the  promotion  of  health,  a  real  though 
slowly  growing  part  of  their  function,  the  primary  reason  for  the  utilization 
of  hospitals  a*nd  dispensaries  is  the  occurrence  of  sickness  or  accident.  When- 
ever illness  or  accident  comes,  the  individual  or  the  family  must  reach  a 
decision  as  to  what  is  to  be  done.  Choice  must  be  made  among  possible 
resources.  It  is  well  to  list  these  resources  so  that  all  of  the  elements  of  the 
picture  shall  be  in  mind.  A  list  of  ten  resources  for  the  care  of  illness  might 
be  included: 

1.  The  home  remedy, 

2.  The  advice  of  friend,  grandmother,  or  neighbor  of  reputed  wisdom, 

3.  The  private  physician, 

4.  The  drug  store, 

5.  The  physician  of  an  organization  of  which  the  patient  or  family  is  a 

member    (for    instance,    lodge    doctor,    industrial    physician,    city 
physician), 

6.  The  quack  doctor  or  medical  institute,  .     . 

7.  The  midwife  (for  obstetrical  care), 

8.  The  nurse, 

9.  The  hospital, 
10.  The  dispensary. 

The  attitude  of  a  community  towards  its  hospitals  and  dispensaries  is 
made  up  of  the  points  of  view  of  its  individual  citizens.  These  points  of 
view  are  practically  expressed  in  determining  what  choice  is  made  among 
the  resources  for  the  care  of  sickness.  Such  choice  or  decisions  are  influenced 
by  considerations  of  finances,  but  also  by  custom,  personal  connections, 
prejudices  and  information  or  misinformation  regarding  the  availability, 
powers  and  prestige  of  the  various  resources  for  the  care  of  a  given  case  of 
illness  or  accident. 


It  is  obvious  that  the  ten  resources  for  the  care  of  illness  vary  in  their 
grade  of  efficiency.  It  is  obvious  that  the  various  elements  in  the  popula- 
tion select  resources  differently.  Thus  the  use  of  the  midwife  is  largely  con- 
fined to  foreigners;  the  quack  reaps  his  richest  harvest  from  among  the  less 
educated;  the  service  of  the  dispensary  at  the  present  time  is  chiefly  for 
those  of  limited  means.  One  man  with  a  pain  in  his  back  goes  to  a  dispen- 
sary. Another  equally  unblessed  with  this  world's  goods  hies  himself  to  a 
drug  store  and  purchases  and  applies  a  widely  advertised  "Rheumatic's 
Ready  Relief."  One  woman  goes  to  a  hospital  for  an  operation;  her  neigh- 
bor two  blocks  away  refuses  to  go  to  an  institution  even  on  the  advice  of  .her.. 


Hospitals  and  Dispensaries  821 


family  physician,  because  she  is  "afraid  of  hospitals."  A  member  of  a 
lodge  utilizes  the  services  of  the  official  doctor  of  the  organization  during  a 
minor  illness,  but  when  he  thinks  something  serious  is  the  matter  with  him, 
he  calls' a  "real  doctor,"  meaning  one  whom  he  pays.  Quacks'  offices  are 
thronged  with  thousands  of  credulous  victims,  and  the  mails  are  filled  with 
money  directed  toward  the  coffers  of  patent  medicine  vendors.  Choices 
among  the  resources  available  for  the  care  of  sickness  are  as  varied  as  the 
circumstances  surrounding  each  case,  and  as  manifold  as  human  nature 
itself. 

A  health  survey  of  Cleveland  might  theoretically  arrange  the  ten  resources 
for  the  care  of  illness  in  the  order  of  their  relative  efficiency,  and  then  study, 
for  different  sections  of  the  population,  their  usual  order  of  utilization 
for  different  kinds  of  sickness  or  accident.  Such  a  study  cannot  practically 
be  made,  but  supposing  for  the  sake  of  argument  that  it  could  be  made,  let 
us  ask  this  question:  would  the  order  of  utilization  by  the  people' of  the  ten 
resources  for  the  care  of  illness  correspond  to  their  order  of  relative  efficiency? 
In  so  far  as  it  does  not,  the  well-being  of  the  community  suffers.  Reputable 
physicians  and  the  hospitals  and  dispensaries  in  which  these  physicians  ren- 
der service,  obviously  constitute  the  primary  and  fundamental  medical  re- 
sources for  the  care  of  illness  and  the  promotion  of  health..  Are  they  used' 
with  the  degree  of  fullness  and  of  discrimination  with  which  they  should  be? 
If  not,  why  not?  The  answer  would  not  be  the  same  for  all  groups  of  the 
population. 

A  study  of  the  hospitals  and  dispensaries  of  Cleveland  cannot  rightly  be 
limited  to  the  amount  and  the  nature  of  the  work  done,  the  internal  adminis- 
tration, and  other  technical  problems,  important  as  these  are.  It  needs  also 
to  include  a  study  of  the  attitude  of  different  sections  of  the  people' — the 
medical  profession,  the  well-to-do,  the  poor,  the  foreign-born,  etc.,  toward 
these  institutions.  It  is  on  the  basis  of  these  attitudes,  understandings  or 
misunderstandings,  that  the  choice  among  medical  resources  is  made  in  time 
of  sickness  or  accident,  and  upon  which  the  utilization  of  hospital  and  dis- 
pensary for  the  benefit  of  the  public  ultimately  rests.  Financial  support  of 
hospitals  and  dispensaries  by  the  community  depends  precisely  on  the  same 
considerations.  In  this  section  of  the  report  of  the  Cleveland  Hospital  and 
Health  Survey,  therefore,  an  endeavor  will  be  made  to  review  the  details 
of  the  work  of  the  hospitals  and  dispensaries  of  the  city,  in  their  medical, 
administrative  and  financial  aspects,  and  to  consider  also  the  relation  of 
these  institutions  to  the  various  sections  of  the  public  which  use  them  or  need 
to  use  them.  Hospitals  and  dispensaries  represent  or  ought  to  represent 
the  organization  of  medical  services  upon  a  scientific  basis,  bringing  to  bear 
upon  the  needs  of  the  individual  patient  the  maximum  resources  in  equip- 
ment and  skill  that  twentieth  century  medical  science  can  muster.  To  pro- 
mote a  better  understanding  of  hospitals  and  dispensaries  by  the  community 
is  to  promote  at  the  same  time  their  better  and  more  discriminating  utilization, 
and  their  more  effective  and  generous  support. 


822 Hospital  and  Health  Survey 

SOME  DEFINITIONS 

The  hospital  and  the  dispensary,  taken  together,  comprise  what  may  be 
called  the  organized  or  institutional  practice  of  medicine.  In  the  private  prac- 
tice of  a  physician,  some  patients  are  seen  in  his  office,  others  in  bed  in  their 
own  homes  or  in  a  private  room  of  an  institution.  In  the  institutional 
practice  of  medicine  the  dispensary  patients  correspond  to  those  who  are 
seen  in  the  physician's  office,  and  the  hospital  patients  to  those  whom  he 
sees  in  bed. 

During  the  winter  of  1919  and  spring  of  1920,  when  the  Survey  was  made, 
there  were  47  institutions  known  as  hospitals,  and  26  dispensaries  and  health 
centers  in  Cleveland  and  Lakewood.  Under  a  law  of  Ohio  which  became 
effective  in  1919,  all  hospitals  and  dispensaries  must  be  registered  with  the 
State  Department  of  Health  and  render  to  it  an  annual  report.  Eight  of  the 
above  47  "hospitals"  had  not  registered  with  the  State  Department  of 
Health  at  the  time  the  field  work  of  the  Survey  was  completed  (June,  1920). 
Their  names  were  found  in  the  telephone  directory.  They  are  not  further 
referred  to  in  this  report,  except  in  relation  to  the  public  supervision  of  hos- 
pitals, in  the  section  on  "Organization  to  Carry  Out  Plans."  The  definition 
of  dispensary  as  thus  far  interpreted  by  the  State  Department  of  Health 
does  not  appear  to  include  the  Health  Centers  or  clinics  doing  primarily 
preventive  work. 

The  medical  institutions  of  Cleveland  may  be  further  divided  according 
as  they  are  members  of  the  Cleveland  Hospital  Council  or  not.  Table  I. 
in  the  Appendix  gives  the  hospitals  and  dispensaries  of  Cleveland,  stating 
after  each  the  approximate  number  of  beds  in  the  hospital,  and  the  approxi- 
mate number  of  annual  visits  by  patients  to  the  dispensary. 

On  the  accompanying  map  these  institutions  are  shown  in  their  proper 
location. 

It  is  important  to  state  certain  definitions  and  distinctions  which  will  be 
of  service  in  understanding  the  problems  and  relations  of  the  hospitals  and 
dispensaries  of  Cleveland. 

Hospitals  may  be  broadly  classified  in  two  ways:  first,  according  to  the 
character  of  diseases  treated,  and,  second,  according  to  the  relation  of  the 
institution  to  the  community. 

With  regard  to  the  character  of  diseases  treated,  the  distinction  is  between 
general  hospitals,  such  as  City  or  Lakeside  Hospitals,  and  special  hospitals, 
such  as  Cleveland  Maternity  or  St.  Ann's  Maternity  Hospital.  The  latter 
receive  only  patients  of  a  designated  medical  type.  It  will  be  observed  at 
once  that  Cleveland  has  few  of  the  second  group. 

On  the  other  basis  of  classifying  hospitals  in  their  relation  to  the  com- 
munity, two  divisions  may  be  made: 

(a)  Public-service  hospitals. 

(b)  Proprietary  hospitals. 


»  ? 

c1* 


823 


824  Hospital  and  Health  Survey 


The  first  class  receive  patients  as  a  public  service,  whether  pay,  part-pay 
or  free  patients.  The  second  class  are  conducted  as  corporations  for  the  profit 
of  their  owners.  It  is  important  to  notice  that  the  term  "private  hospital," 
which  is  not  infrequently  used,  is  decidedly  ambiguous.  The  word  ''private" 
is  sometimes  employed  to  indicate  a  hospital  supported  by  private  funds  as 
distinguished  from  a  state  or  a  municipal  hospital.  In  another  sense,  a 
private  hospital  is  taken  to  mean  one  which  receives  only  private  ratients  of 
certain  physicians  and  no  ward  or  "staff"  patients.  In  still  a  third  sense, 
the  word  "private"  is  applied  to  a  hospital  which  is  conducted  as  a  private 
business  for  profit.  To  use  the  same  word  "private"  for  a  hosrital  which 
is  performing  a  great  amount  of  public  service  rendered  alike  to  those  who 
pay  and  those  who  do  not  pay,  as  for  an  institution  which  is  run  as  a  business 
enterprise,  involves  dangerous  confusion.  The  term  "proprietary"  makes 
the  proper  distinction. 

This  term,  however,  is  not  necessarily  one  of  reproach.  It  is  perfectly 
legitimate  and  proper  for  an  individual  or  a  corporation  to  maintain  a  hos- 
pital for  profit,  as  a  business  enterprise.  Such  an  institution  corresponds  to 
a  "private  school"  or  "academy,"  and  may  be  as  well  conducted  and  as 
useful  to  a  limited  circle  of  patients  as  are  many  well  known  private  schools 
to  their  clientele. 

As  will  appear  later,  a  number  of  institutions  in  the  above  list  fall  within 
the  proprietary  class.  There  are  some  of  these  hospitals  which  were  'ncorpo- 
rated  as  business  organizations  to  be  run  for  profit,  but  which  in  practice  are 
conducted  as  oublic  service  institutions,  and  have  been  so  recognized  by  the 
Cleveland  Hospital  Council.  According  to  the  principles  which  will  be  laid 
down  in  this  report,  the  extent 'to  which  the  public  should  assist  financially 
in  the  maintenance  of  a  hospital  should  vary  in  orecise  degree  with  the  amount 
and  proportion  of  public  service  rendered  by  the  institution.  To  be  able  tc 
measure  this  accurately  and  to  make  the  results  of  this  measurement  known 
to  the  public  or  to  the  agency  representing  the  public,  such  as  the  Community 
Fund,  is  one  of  the  important  aims  which  those  interested  in  hospitals  must 
have  in  view. 

The  degree  of  public  service  rendered  by  a  hospital  does  not  correspond 
with  the  number  of  its  free  patients.  Some  persons  have  the  notion  that 
doing  charity  means  giving  something  for  nothing.  The  twentieth  century 
idea  of  charity  is  a  service,  not  a  dole.  The  public  service  rendered  by  a 
hospital  should  be  measured  from  a  financial  standpoint  by  the  amount  of 
rare  given  at  a  rate  lower  than  the  cost  of  the  service.  This  in  practice  means 
measured  by  the  number  of  days  of  care  rendered  during  the  course  of  a  year. 
If  a  patient  is  treated  for  a  day  and  pays  only  half  the  cost  of  the  service, 
the  hospital  may  be  credited  with  one-half  of  a  day's  free  care.  Such  is  a 
simple  method  of  estimating  the  financial  aspect  of  the  public  service  of  a 
hospital. 

From  the  professional  standpoint,  public  service  must  be  estimated  in 
terms  of  kind  and  standard  of  care,  a  more  technical  and  difficult  matter  to 
evaluate.  Classification  of  hospitals  according  to  the  quality  of  service,  an 
invidious  task,  fan  be  undertaken  here  only  with  reference  to  one    distinc- 


Hospitals  and  Dispensaries  825 

lion.     The  public  ought  to  understand  the  difference  between  the  "medical 
boarding  house"  and  the  hospital. 

In  every  large  city  are  found  institutions,  usually  of  the  proprietary  class, 
which  have  an  operating  room,  a  nursing  service,  and  which  receive  the 
patients  of  private  physicians,  put  them  to  bed,  nurse  and  feed  them,  and 
provide  for  nursing  attendance  at  operation  if  the  case  is  surgical.  The  pri- 
vate physician  carries  the  same  individual  responsibility  that  he  would  if 
the  patient  were  in  bed  at  home.  The  difference  is  merely  that  there  are 
facilities  for  a  major  operation  close  by,  and  that  the  patient's  household  is 
spared  the  difficulties  of  adjustment  to  illness,  the  introduction  of  a  trained 
nurse,  provision  for  a  special  diet,  etc.  These  are  to  all  intents  and  purposes 
medical  boarding  houses. 

The  modern  hospital  is  as  different  from  a  medical  boarding  house  as  a 
passenger  liner  is  from  a  tramp  steamer.  Both  float  and  both  will  take  one 
somewhere.  But  one  is  just  a  boat,  while  the  other  is  a  boat  plus  an  organ- 
ization. 

The  modern  hospital  provides  the  physician  with  certain  facilities  which 
are  unavailable  in  the  patient's  home.  Medical  practice  today  requires 
more  than  the  physician's  individual  trained  senses.  Laboratories  for  many 
te^ts  and  an  X-Ray  department  are  necessary  adjuncts  to  modern  medical 
practice.  The  patient  cared  for  at  home  can  secure  these  benefits  only 
through  expensive  and  somewhat  slow  recourse  to  private  laboratories.  In 
the  hospital,  this  equipment  and  a  vast  variety  of  other  instruments  and 
apparatus  are  brought  together  under  a  single  roof,  and  organized  under  a 
single  control,  so  as  to  be  most  economically  and  effectively  used.  Modern 
me  rcine  also  is  highly  specialized.  No  one  physician  can  master  all  the 
science.  Many  cases  require  examination  and  study  by  physicians  each 
representing  a  different  branch  of  medicine,  in  order  that  all  the  necessary 
facts  be  obtained,  and  through  consultation  an  accurate  diagnosis  of  the 
disease  be  established.  The  staff  of  a  modern  hospital  provides  a  group  of 
specialists  working  with  joint  equipment,  and  under  a  mutually  acceptable 
plan  of  team  work,  which  should  render  the  service  of  each  of  maximum 
value  to  the  others  as  well  as  to  himself  and  to  the  patient. 

Similarly  the  modern  hospital  provides  assistants  to  the  physician  of 
special  skill;  the  medical  assistant,  the  interne;  the  laboratory  assistant, 
the  technician;  the  nurse,  and  the  social  worker.  Through  the  aid  of  these 
assistants  the  highly  special  skill  of  the  physician  is  kept  for  just  that  kind 
of  work  which  requires  it,  and  his  time  is  not  spent  on  routine  or  details. 
Consequently  with  a  given  expenditure  of  time  and  energy  he  can  render 
service  to  a  much  larger  number  of  patients,  and  more  effective  service 
at  that. 

A  modern  hospital  may  be  defined  as  an  institution  in  which  there  is 
joir  t  use  of  medical  equipment  and  cooperative  organization  of  medical 
skill  for  the  diagnosis,  treatment  and  prevention  of  disease. 

A  critical  study  of  hospitals  makes  it  clear  that 'some  institutions  main- 
tain the  principles  of  the  medical  boarding  house  with  respect  to  their  private 


826  Hospital  and  Health  Survey 

I  atients,  while  having  a   well  organized  system  for  modern  hospital  work 
\\*ith  respect  to  their  ward  cases.     Is  privacy  a  substitute  for  service? 

The  distinction  between  the  two  types  of  services  will  be  illustrated  in 
numerous  ooints  during  the  course  of  this  report,  and  will  be  of  importance 
in  connection  with  certain  final  conclusions.  Each  hospital  trustee  and  every 
hospital  patient  will  do  well  to  see  how  these  principles  work  out  with  re- 
gard to  the  hospital  which  he  knows  best. 

The  dispensaries  may  be  classified  as  are  the  hospitals.  As  a  matter  of 
fact,  the  list  of  dispensaries  on  pages  984-986  contains  none  of  the  pro- 
prietary class.  There  are  indeed  some  clinics  maintained  in  Cleveland  by 
individual  physicians,  whether  on  their  own  account  or  in  connection  with 
industrial  establishments.  Some  of  these  are  reputable  enterprises;  some  of 
them  are  merely  quack  medical  institutes.  The  latter  class  will  be  referred 
to  only  in  connection  with  some  general  recommendations  of  the  Survey  in 
the  section  on  "Organization  to  Carry  Out  Plans,"  as  are  the  hospitals  not 
registered  with  the  State  Department  of  Health. 

Cleveland  has  only  one  dispensary  treating  the  sick  of  the  class  confined 
to  special  diseases — the  Babies'  Dispensary.  Its  clientele  is  limited  to  chil- 
dren not  over  three  years.  A  highly  important  group  of  special  dispensaries, 
however,  are  the  public  health  dispensaries,  which  aim  to  prevent  rathei 
than  treat  disease,  to  educate  rather  than  to  cure — the  Health  Centers, 
Baby  Prophylactic  Stations,  and  Prenatal  Clinics.  Broadly  speaking,  a  line 
for  the  support  of  dispensary  work  is  drawn  by  the  municipal  authorities  on 
the  border  line  between  preventive  and  curative  medicine;  private  support 
of  dispensary  work  being  largely  though  not  wholly  confined  to  the  dispen- 
saries treating  the  sick,  and  public  support  being  almost  entirely  confined  to 
the  dispensaries  whose  work  is  primarily  preventive  and  educational. 

The  term  "dispensary"  originally  meant  a  place  where  medicine  was 
given  out  or  dispensed  to  the  poor  on  the  prescription  of  a  physician,  and  the 
word  has  persisted,  although  at  the  present  day  the  giving  out  of  medicine 
is  a  minor  function  of  a  dispensary.  Medical  diagnosis,  advice,  and  treat- 
ment other  than  medicine  are  the  services  of  primary  significance.  The 
term  "out-patient  department"  is  frequently  used  as  synonymous  with  dis- 
pensary when  applied  to  a  dispensary  which  is  part  of  the  organization  of  a 
hospital — the  bed  cases  being  the  in-patient  department  and  the  dispensary 
the  out-patient  department.  In  this  report,  the  term  dispensary  will  be 
generally  used  except  when  it  is  desired  to  draw  a  special  distinction  between 
the  "in"  and  the  "out"  patients. 

The  unit  for  measurement  of  the  services  rendered  by  hospitals  and  dis- 
pensaries is  important  to  define.  Hospital  service  is  measured  in  days  of 
care.  A  patient  who  has  been  in  the  hospital  for  two  weeks  has  in  this  sense 
received  fourteen  units  of  service.  The  unit  for  measuring  dispensary  serv- 
ice is  the  visit  paid  by  the  patient  to  the  clinic.  It  will  be  observed  that  the 
visits  paid  by  patients  to  a  dispensary  in  the  course  of  a  month  or  of  a  year 
is  much  more  than  the  number  of  individuals  treated,  just  as  the  number  of 
days'  care  given  patients  in  a  hospital  is  much  larger  than  the  number  of 


Hospitals  and  Dispensaries  827 


different  patients.  In  actually  studying  the  work  of  a  given  institution  or 
of  the  city  as  a  whole,  we  are  of  course  interested  in  the  number  of  individuals 
cared  for  as  well  as  in  the  bulk  of  service  rendered.  Days  of  hospital  care 
and  visits  to  dispensary  clinics  represent  the  latter  element — bulk  of  work 
done.  The  number  of  individuals  treated  is  in  practice  a  more  difficult 
figure  to  obtain,  because  of  the  likelihood  of  the  same  individual,  in  case  of 
readmission  to  dispensary  or  hospital,  being  counted  as  a  different  patient. 

One  of  the  fundamental  problems  of  every  professional  institution  today 
is  how  to  make  a  specialized  and  technical  piece  of  work  clear  to  the  average 
person.  The  problem  is  to  interpret  hospitals  and  dispensaries  to  the  com- 
munity. This  means  stating  facts  showing  the  kind,  amount  and  quality 
of  service  rendered,  and  stating  them  in  such  a  way  that  they  are  easily 
understood  by  the  average  person.  It  is  of  relatively  little  importance 
what  facts  a  temporary  survey  gathers  and  reports — such  facts  are  at  most 
only  a  cross-section,  a  momentary  picture.  It  is  of  very  great  importance 
what  facts  the  hospitals  and  dispensaries  gather  and  present  regularly  to 
the  public,  and  how  they  present  them  to  the  unprofessional  mind — whether 
in  a  vivid  and  convincing  fashion  or  in  dry  and  technical  form.  What  a 
board  of  trustees  needs  to  know  about  their  own  hospital  or  dispensary; 
what  the  contributors  to  the  Community  Fund  need  to  know  about  all 
hospitals  and  dispensaries;  what  the  general  public  needs  to  know  about 
the  hospitals  as  a  whole  or  about  its  municipal  institution  in  particular — 
these  are  of  fundamental  importance  for  the  Survey  to  suggest. 

The  cost  of  maintaining  medical  institutions  has  been  increasing  with 
great  rapidity,  not  only  because  of  the  general  rise  in  prices,  but  because  of 
advance  in  medical  science,  the  more  elaborate  equipment  that  is  necessary, 
the  higher  specialization  in  many  branches — in  a  word,  higher  standards  of 
service,  yielding  better  results  for  the  cure  and  prevention  of  disease.  Public 
comprehension  of  these  new  and  higher  standards  has  lagged  behind  their 
establishment  in  the  strongest  institutions.  Such  comprehension  forms  the 
basis  on  which  taxes  for  municipal  institutions  must  be  levied  and  cam- 
paigns for  community  chests  or  for  building  funds  successfully  accomplished. 
Adequate  moral  and  financial  support  of  hospitals  and  dispensaries  depends 
upon  making  these  standards  and  needs  clear  in  terms  of  human  interest 
and  popular  understanding.  The  defining  of  units,  the  assembling  of  sta- 
tistics and  the  compilation  of  professional  reports  are  fundamental  prerequi- 
sites. The  statement  and  interpretation  of  these  data  to  the  community 
are  a  necessary  sequence. 


828  Hospital  and  Health  Survey 


II.      Hospitals 

HOSPITAL  PROVISIONS  AND  COMMUNITY  NEEDS 

Reserving  the  study  of  dispensaries  for  Chapter  III.,  we  may  now  com- 
pare the  hospital  facilities  of  Cleveland  with  those  of  other  communities 
and  with  the  probable  needs  of  the  city. 

During  the  winter  of  1920,  while  the  Survey  was  in  progress,  the  number 
of  hospital  beds  in  the  cities  of  Cleveland  and  Lakewood  was  3,378,  including 
all  the  institutions  registered  with  the  State  Department  of  Health. 

Of  these,  3,088  beds  were  in  the  20  hospitals  of  the  Cleveland  Hospital 
Council,  as  follows: 


Beds 

Cleveland  City  Hospital :...  785 

Cleveland  Maternity  Hospital ,  60 

Fairview  Park  Hospital 85 

Glenville  Hospital 74 

Grace  Hospital 35 

Huron  Road  Hospital..... 84 

Lakeside  Hospital. 289 

Lakewood  Hospital 53 

Lutheran  Hospital , 50 

Mount  Sinai  Hospital 225 

Provident  Hospital 29 

Rainbow  Hospital 85 

St.  Alexis  Hospital 250 

St.  Ann's  Maternity  Hospital 55 

St.  Clair  Hospital 43 

St.  John's  Hospital 150 

St.  Luke's  Hospital 139 

St.  Vincent's  Charity  Hospital 290 

Warrensville  Tuberculosis   Sanatorium 270 

Woman's  Hospital — 37 

Total -  3,088 


Hospitals  and  Dispensaries  829 


The  11  non-council  hospitals  included  290  beds,  as  follows: 

Beds 

Cleveland  Emergency  Hospital = 22 

Cleveland  Home  Hospital - 10 

East  Cleveland  Hospital '. 31 

East  Fifty-fifth  Street  Hospital - 60 

East  Seventy-ninth  Street  Hospital 22 

Florence  Crittenden  Home - 12 

Joanna  Private  Hospital 9 

Mrs.  Hitchcock's  Private  Hospital - 15 

St.  Mark's  Hospital..! 45 

Salvation  Army  Rescue  Home 54 

Wright's  Hospital .' 10 

i 

Total..... 290 

In  this  classification  it  is  to  be  noted  that  in  conformity  with  the  usual 
practice,  beds  (1)  for  the  insane  and  feeble-minded,  (2)  for  the  infirm  and 
aged,  (3)  in  orphanages,  and  (4)  under  the  control  of  the  United  States 
Government,  have  not  been  included.  The  list  includes  hospitals  for  general 
and  special  cases  of  an  acute  or  chronic  nature,  and  convalescents,  but  not 
the  four  classes  mentioned  above.  This  point  is  important  in  making  com- 
parisons with  other  communities. 

If  these  beds  are  compared  with  the  population  of  the  cities  of  Cleveland 
and  Lakewood,  taken  together,  we  should  find  that  there  are  3,378  beds  to 
a  population  of  approximately  840,000  in  these  two  cities.  However,  these 
beds  are  serving  more  than  the  population  of  Cleveland  and  Lakewood. 
They  are  used  by  what  may  be  called  the  metropolitan  district,  and  even 
more  distant  areas  depend  upon  them.  We  may  form  a  definite  estimate 
from  data  collected  by  the  Survey  on  the  two  days,  December  3,  1919,  and 
January  15,  1920,  on  each  of  which  was  taken  a  census  of  the  patients  in  the 
Council  hospitals  and  in  three  others.  A  tabulation  of  the  patients  in  these 
hospitals  on  these  two  days  by  location  of  residence(the  average  of  the  two 
days)  showed  that  of  the  2,651  patients  14.7  per  cent.,  or  practically  one- 
seventh,  came  from  outside  the  city  of  Cleveland.  This  number  includes  of 
course  those  coming  from  Lakewood,  but  it  is  certain  that  at  least  one-eighth 
of  the  patients  who  were  in  the  hospitals  on  these  two  days  came  from  out- 
side Ceveland  or  Lakewood.  At  least  one-eighth  therefore  should  be  added 
to  the  population  served  by  the  hospitals  on  our  list,  which  would  make  a 
total  of  about  945,000.  Dividing  this  by  the  number  of  beds,  3,378,  we  find 
that  there  is  provision  to  the  extent  of  about  2.8  beds  to  one  thousand  of 
popu'ation.  This  is  a  fundamental  figure,  because  it  is  an  index  of  the  de- 
gree of  provision  of  hospital  service  for  community  needs.  Its  significance 
will  require  elucidation. 


830  Hospital  and  Health  Survey 


Comparisons  must  needs  be  made  with  other  communities.  In  the  1919 
report  of  the  United  Hospital  Fund  of  New  York  City,  a  classified  list  is 
given  of  the  hospitals  in  that  metropolis.  There  is  shown  a  total  of  28,2C8 
beds,  which  does  not  include  the  four  classes  of  institutions  mentioned 
above,  or  many  small  private  institutions  such  as  appear  in  the  Cleveland 
list  among  the  non-council  hospitals.  The  proportion  of  patients  coming 
from  outside  the  limits  of  Greater  Xew  York  is  not  known,  but  most  of  the 
suburbs  of  Xew  York  are  better  provided  with  hospitals  than  the  outlying- 
districts  of  Cleveland.  It  is  assumed  that  the  omissions  from  the  list  of  hospitals 
in  Xew  York  given  by  the  United  Hospital  Fund  would  probably  balance  in 
number  the  beds  required  to  serve  non-residents.  On  this  basis,  provision 
of  hospital  beds  in  the  metropolis  in  proportion  to  population  is  five  per 
thousand. 

Boston  provides  another  basis  of  comparison.  The  legal  city  of  Boston  is 
a  little  smaller  than  Cleveland,  according  to  the  1920  census,  727,000  against 
796,836,  but  Boston  is  one  of  some  38  towns  and  cities  within  the  metro- 
politan district,  with  a  total  population  of  approximately  1,500,00D.  A  list 
of  hospitals  in  this  "Greater  Boston"  showed,  from  figures  in  the  Medical 
Directory  of  1918,  140  hospitals,  general  and  special  (excluding  those  types 
above  named)  with  a  total  of  7,247  beds.  This  is  4.83  beds  to  1,000  of  popu- 
lation. 

Taking  the  city  of  Boston  alone,  with  a  census  population  in  1920  of 
727,000,  it  was  found  that  there  were  108  hospitals,  with  6,062  beds.  This 
is  an  average  of  8.3  beds  to  1,000  population,  but  this  figure  should  not  be 
used  for  comparative  purposes,  since  so  large  a  proportion  of  the  Boston  beds 
are  used  by  the  metropolitan  district,  with  double  the  population  of  Boston 
proper.  For  purposes  of  comparison  with  Cleveland,  the  figure  for  the 
metropolitan  area  should  be  taken.  It  will  be  observed  that  the  figures  for 
Xew  York  and  for  "Greater  Boston"  are  almost  exactly  the  same. 

It  is  apparent  that  Cleveland  falls  far  below  either  Boston  or  Xew  York 
in  providing  hospital  service  in  proportion  to  its  population.  On  the  basis 
of  five  beds  per  thousand  Greater  Cleveland  needs  fully  4,725  beds,  or  at  least 
1,350  more  than  now  exist.  In  view  of  the  fact  that  even  when  new  beds  are 
planned  for,  time  is  required  to  build  and  equip  the  hospitals  to  contain  them 
and  that  population  needs  continue  to  grow,  it  may  be  conservatively  esti- 
mated that  Cleveland  needs  to  add  1,500  beds  to  its  hospital  capacity  as 
quickly  as  possible.  Even  at  the  present  moment  (June,  1920)  it  must  be 
recalled  that  while  the  1920  census  showed  a  smaller  population  for  Cleve- 
land than  had  been  anticipated,  yet  the  growth  of  the  suburbs,  which  must 
depend  largely  upon  the  main  city  for  their  hospital  service,  has  been  pro- 
reeding  at  such  a  rapid  rate  that  it  is  fair  to  estimate  that  not  less  than  1,500 
rather  than  1,300  beds  should  be  stated  as  the  shortage  in  the  year  1920. 

Were  this  merely  a  conclusion  derived  from  statistics,  it  would  be  indeed 
questionable.  The  statistics,  however,  are  worked  out  merely  to  give  an 
index  to  well-established  facts  showing  the  shortage  of  hospital  beds  in 
Cleveland  and  the  unfortunate  results  of  this  shortage.     To  depict  these 


Hospitals  and  Dispensaries  831 


will  require  a  closer  analysis  of  the  service  offered  by  the  hospitals  of  the 
city. 

The  hospitals  of  Cleveland  are  predominantly  devoted  to  surgery.  On 
the  two  Survey  census  days,  if  the  hospitals  of  the  city  were  taken  together 
(omitting  City  Hospital,  Warrensville  Tuberculosis  Sanatorium,  andRainbow 
Hospital),  it  was  found  that  48  per  cent,  of  the  patients  were  surgical, 
and  that  in  the  majority  of  the  hospitals  the  ratio  was  much  higher.  The 
reason  that  City  Hospital  is  excluded  is  because  in  its  785  beds  are  included 
large  groups  of  cases  such  as  tuberculous,  alcoholic,  venereal  disease  and 
contagious. disease  patients,  which  do  not  appear  in  any  other  hospital.  On 
the  census  days,  only  21.5  per  cent,  of  the  patients  represented  general  medi- 
cine, and  only  9.4  per  cent,  special  services.  18.7  per  cent,  were  obstetrical, 
and  2.4  per  cent,  not  stated.     The  figures  themselves  are  given  in  a  footnote.* 

Cleveland  is  seriously  deficient  in  provision  for  special  classes  of  cases,  f 
Obstetrical  cases  are  found  in  the  majority  of  the  hospitals.  The  average 
for  the  two  census  days  was  313,  or  about  one  patient  in  ten,  9.3  per  cent,  of 
the  total  patients  in  the  Cleveland  hospitals  on  those  days.  Provision  for 
obstetrical  cases  in  special  hospitals  is  made  only  at  Cleveland  Maternity 
Hospital  and  at  St.  Ann's  Maternity  Hospital,  a  total  of  115  beds.  Recent 
years  have  seen  a  great  increase  in  the  demand  for  care  in  hospitals  at  the 
time  of  confinement,  particularly  by  middle-class  families,  but  these  cases  have 
had  in  the  main  to  be  provided  for  in  the  general  hospitals,  without  the  de- 
velopment of  special  hospitals,  special  services,  or  special  wards  to  meet  the 
particular  need. 

Regarding  cases  of  eye  disease,  it  was  found  that  only  one  hospital, 
Lakeside,  makes  any  special  reservation  of  beds,  four  beds  being  held  in  the 
male  surgical  ward  of  Lakeside  for  this  service.  There  is  no  special  ward  in 
the  city  for  ear,  nose  and  throat  cases.  In  Xew  York  608  beds  are  provided 
in  special  institutions  for  eye,  ear,  nose,  and  throat  cases,  aside  from  such 
provision  as  is  made  in  the  general  hospitals.  In  Boston,  219  beds  are  pro- 
vided; in  Baltimore,  153;  in  Philadelphia,  58;  in  Chicago,  32. 

In    special    provision    for    children,     Cleveland    is    similarly    lacking. 

Pediatric  services  exist  at  Lakeside,  City  and  Mount  Sinai,  and  beds  are  set 
aside  for  children  in  the  following  additional  hospitals:  Children's  Fresh  Air 
Camp,  Fairview  Park  Hospital,  Huron  Road  Hospital,  Lakewood  Hospital, 
Rainbow  Hospital,  St.  Alexis  Hospital,  St.  Ann's  Hospital,  St.  John's  Hos- 
pital, and  St.  Luke's  Hospital,  making  a  total  of  302  beds  designated  as  chil- 
dren's  beds,  for  other  than  contagious  or  convalescent  cases. 

* Classification  of  Patients,  Census  Days  (averaged i 
Type  of  Service 

Medical 

Surgical 

Obstetrical 

Special . 

Not  stated 

tin  1918  Boston  had  beds  in  special  institutions  to  the  number  of  2698,  as  follows: 

Tuberculosis 792  Children 240 

Eye  and  ear 225  Women  (maternity) 436 

Contagious.. 340  Women  and  children  together 542 

-Cancer 25  Convalescent 98 


umber 

Percentage 

361.0 

21.5 

805.5 

48.0 

312.5 

18.7 

157.5 

9.4 

40.0 

2.4 

832  Hospital  and  Health  Survey 


It  will  be  observed  that  these  are  all  parts  of  general  hospitals.  As  com- 
pared with  this,  New  York  has  1,298  beds  for  children  in  special  hosritals, 
and  in  addition,  at  least  as  many  more  beds  specially  set  aside  for  children 
in  a  number  of  general  hospitals;  Boston  has  about  240  beds  for  children  in 
special  hospitals  and  more  than  that  in  pediatric  divisions  of  a  number  of 
general  hospitals. 

On  the  two  census  days,  there  were  496  children  found  in  the  Cleveland 
hospitals,  of  whom  57  were  in  the  contagious  disease  service  of  City  Hos- 
pital. The  vast  majority  of  the  remaining  439  were  scattered  through  the 
wards  and  rooms  of  general  hospitals,  the  greater  number  being  surgical 
cases. 

In  the  matter  of  provision  for  contagious  cases,  Cleveland  has  100  beds 
at  City  Hosoital.  Boston  has  340  beds  in  its  City  Hosoital.  In  connection 
with  contagious  diseases,  these  figures  are  comparable,  since  both  institutions 
rarely  take  cases  except  from  within  the  limits  of  the  legal  city.  It  is  stated 
by  such  a  national  authority  as  Dr.  Charles  V.  Chapin  that  for  the  common 
contagious  diseases  (excluding  tuberculosis,  venereal  diseases,  etc.),  a  com- 
munity should  provide  at  least  one  bed  for  every  2,000  of  pooulation.  This 
in  Cleveland  would  mean  almost  400  beds.  Boston  it  will  be  observed  has 
measured  up  to  Doctor  Chapin's  estimate;  New  York,  with  2,100  beds  for 
contagious  cases,  almost  meets  it. 

A  special  report  of  the  Survey  dealing  with  tuberculosis  (Part  IV.)  has 
shown  that  Cleveland  has  not  enough  beds  for  this  disease. 

The  estimates  of  the  specialists  in  venereal  disease  are  to  the  effect  that 
at  least  200  beds  should  be  provided  in  the  City  Hospital,  and  that  a  certain 
amount  of  provision  should  be  made  in  general  hospitals.    (See  Part  V.) 

In  the  orthopedic  service,  a  branch  of  medicine  of  rapidly  increasing  im- 
portance, Cleveland  has  an  insignificant  provision.  The  number  of  reported 
orthopedic  cases  in  hospital  beds,  at  the  time  of  the  Survey,  was  not  known, 
except  at  Rainbow  Hospital,  which  is  chiefly  designed  for  convalescent 
orthopedic  cases  of  children.  Boston  has  about  three  times  the  provision  for 
orthopedic  cases  as  has  Cleveland,  and  New  York  has  over  360  beds  in 
special  hospitals  alone  for  acute  cases  of  this  type. 

These  facts  go  to  show  where  the  deficiencies  in  provision  of  hospital  beds 
in  Cleveland  lie.  The  reason  for  the  shortage  of  beds  is  obviously  that  the 
population  has  grown  more  rapidly  than  has  recognition  of  needs  for  more 
hospital  service.  We  find  in  the  Cleveland  hospitals  the  more  urgent  sur- 
gical and  some  medical  cases  being  treated,  but  very  little  development  of 
services  for  special  cases.  In  general  it  may  be  said  that  the  urgent  diseases 
or  emergent  cases,  particularly  surgical,  which  force  themselves  on  the  com- 
munity's attention  and  upon  the  attention  of  the  individual  hospitals,  and 
which  cannot  be  denied  admission,  have  left  little  room  for  other  types  of 
work. 

The  effect  of  this  shortage  of  1,500  beds  cannot  be  measured.  We  can  only 
estimate  the  number  of  sick  persons  who  have  had  to  be  cared  for  in  their 
homes  with  inadequate  facilities  for  diagnosis,  for    nursing,  for  diet,  and  for 


Hospitals  and  Dispensaries  833 

care  of  all  kinds.  The  number  of  cas^s  of  disease  needing  the  services  of 
a  specialist,  the  complete  and  thorough  observation  necessary  to  make  a 
diagnosis,  such  as  is  only  possible  under  hospital  conditions,  we  can  only 
infer.  We  can  only  in  imagination  picture  the  suffering  that  has  resulted,  the 
development  of  slight  illness  into  serious,  the  diminution  of  productive  power, 
the  loss  of  opportunity  to  prevent  as  well  as  to  cure  disease.  Such  shortage 
of  hospital  beds  can  only  mean  a  waste  of  the  vital  resources  of  the  popula- 
tion. 

Against  these  figures  ought  to  be  set  others  which  suggest  an  almost 
contradictory  picture.  If  there  were  a  shortage  of  beds,  it  might  seem  at 
first  sight  that  the  3,400  beds  now  available  should  be  constantly  filled  to  their 
capacity.  Such,  however,  is  not  the  case.  On  the  first  census  day,  Decem- 
ber 3,  1919.  2,581  hospital  patients  were  reported  as  in  hospitals  with  a 
theoretical  capacity  at  the  time  of  2,831  beds.  On  the  second  census  day, 
January  15,  1920,  2,663  patients  were  reported  in  hospitals  having  3,001 
beds.  The  percentage  of  beds  filled  on  the  census  days  for  this  group  of 
hospitals,  was  95.7  and  88.7,  respectively. 

A  similar  comparison  can  be  made  on  the  basis  of  an  entire  year,  by  tak- 
ing the  number  of  beds  in  the  hospital  and  multiplying  this  number  by  365, 
thus  securing  the  maximum  days  of  care  that  might  be  given  during  the  year, 
Comparison  of  the  actual  number  of  days'  care,  as  reported,  with  this  figure 
gives  the  proportion  of  utilization  of  hospital  facilities  for  the  year.  For  the 
group  of  seventeen  hospitals  for  which  figures  were  obtained  for  the  year 
1918,  a  total  of  929,825  days  of  care  was  possible  but  only  686,967  days  of 
care  were  given,  or  73.9  per  cent.  During  the  year  1919,  for  a  group  of  six- 
teen hospitals,  a  total  of  930,465  days  of  care  was  possible,  but  only  645,280 
days  of  care  were  given  or  69.3  per  cent. 

It  should  be  stated  at  once  that  we  cannot  expect  a  hospital  or  group  of 
hospitals  to  have  all  beds  filled  all  the  time.  There  are  periods  of  epidemics, 
and  in  normal  times  there  are  occasional  days  when  a  hospital  may  have 
every  bed  taken,  but  such  conditions  are  exceptional.  A  hospital  may  re- 
fuse cases  when  it  has  vacant  beds,  because  there  must  be  classification  of 
patients  to  a  greater  or  less  degree,  and  the  ward  for  which  the  patient  is 
suited  on  account  of  his  sex  or  disease  may  be  full,  while  there  may  be 
vacancies  elsewhere.  Inability  to  receive  a  given  patient  is  thus  compatible 
with  some  vacancies  in  the  same  hospital.  Over  any  considerable  period  of 
time  during  the  year,  there  are  many  reasons  why  a  certain  number  of  beds 
cannot  be  completely  utilized.  Rooms  and  wards  must  be  renovated  and 
occasionally  repairs  are  necessary.  In  many  hospitals  a  certain  number  of 
beds  are  set  aside  for  the  temporary  detention  of  patients,  particularly  chil- 
dren, during  a  period  of  observation  so  as  to  eliminate  risk  of  contagious 
disease. 

Such  are  some  of  the  reasons  why  hospitals  never  show  the  use  of  their 
beds  during  the  year  up  to  anything  like  100  per  cent,  of  capacity.  An 
annual  average  of  75  per  cent,  is  a  very  fair  showing.  During  the  winter 
and  spring  months  there  is  generally  greater  demand  for  hospital  service 


834  Hospital  and  Health  Survey 

than  during  the  summer  and  the  autumn,  and  consequently  a  higher  ratio  of 
use  of  beds  is  usually  found  for  the  six  months  beginning  with  January,  if 
compared  with  the  other  six  months  of  the  year.  Hospital  administrators 
may  take  advantage  of  this  condition  by  doing  repairs  and  renovations,  so 
far  as  possible,  during  the  less  active  months. 

A  tabulation  of  individual  hospitals  presents  some  interesting  points, 
as  shown  by  Table  II  in  the  Appendix. 

It  should  of  course  be  one  of  the  prime  aims  of  hospital  administration 
to  utilize  the  facilities  of  the  plant  to  their  fullest  capacity.  Good  hospital 
administration  should  show  a  higher  average  use  of  beds  than  70  per  cent,  for 
a  year.  Conditions  will  vary  among  general  hospitals.  Conditions  in  special 
institutions,  such  as  hospitals  for  maternity  cases,  children,  chronic  cases, 
etc.,  must  be  considered  on  their  own  merits.  Thus,  in  the  Cleveland  City 
Hospital,  certain  large  units  are  set  aside  for  tuberculosis,, neurology  (includ- 
ing many  alcoholic  cases),  venereal  diseases  and  contagious  cases,  and  the 
demand  for  these  beds  is  affected  by  many  conditions  different  from  those 
which  affect  the  general  medical  and  surgical  services.  It  should,  how- 
ever, be  the  aim  of  hospital  administration  to  make  its  internal  arrangements 
as  flexible  as  possible.*  While  contagious  and  acute  surgical  cases  are  not  safely 
to  be  mixed  in  the  same  wards,  there  should  be  a  constant  effort  toward  the 
utmost  flexibility  of  classification  so  that  pressure  on  one  division  of  the 
service  can  be  relieved  by  rearrangements  which  utilize  beds  vacant  in  other 
divisions. 

A  comparison  of  Cleveland  figures  with  those  of  a  number  of  leading  New 
York  hospitals  shows  the  majority  of  Cleveland  institutions  in  a  somewhat 
unfavorable  light.  Nineteen  hospitals  in  the  United  Hospital  Fund  of  New 
York  showed  in  1919  an  average  of  79  per  cent,  of  their  bed  capacity  filled. 
The  lowest  hospital  showed  63  per  cent,  and  four  showed  90  per  cent,  or  over. 

On  the  whole  it  may  be  said  that  a  general  hospital  should  be  so  adminis- 
tered as  to  run  to  an  average  of  at  least  75  per  cent,  of  its  capacity  during 

*Figures  provided  by  the  City  Hospital  just  before  this  report  goes  to  press  show,  for  the  year  1919 
and  the  fi  st  nine  months  of  1920,  the  details  of  the  use  of  the  different  divisions  of  the  hospital.  These 
are  as  follows:  (The  figures  in  the  parentheses  are  for  the  first  nine  months  of  1920,  and  the  others  for 
the  year  1919.) 


Department 
Tuberculosis 


Contagious 

Specific 

Observation  

Main  and  Convalescent. 


Beds 
100 
(100) 

Total  Days 
Treatment 

Possible 
36,500 

(27,400) 

Total  Days 

Treatment 

Given 

27,447 

(16,430) 

Percentage 

Occupied 

75.7 

(59.9) 

100 
(100) 

36,500 
(27,400) 

14,806 
(13,859) 

40.5 

(50.5i 

75 
(125) 

22,500 
(35,250 

13,575 
(13,264) 

60.3 
(38.7) 

50 
(50) 

18,250 
(13,700) 

12,077 
(  8,938) 

66.2 

(65.0) 

400 

(380) 

146,000 
(104,120) 

105,001 
(   74.614) 

72.0 

(71.7) 

The  very  wide  variations  between  the  degree  of  use  of  the  different  services  of  the  hospital  are  ap- 
parent. It  will  be  noted  that  the  small  percentage  of  use,  particularly  of  certain  divisions,  has  continued 
t  hroughout  a  long  period  of  time. 


Hospitals  and  Dispensaries  835 


the  year  as  a  whole,  and  that  an  average  of  over  80  per  cent,  should  be 
expected  during  the  busier  portion  of  the  year.  A  figure  as  high  as  90  per 
cent,  ought  to  be  the  goal. 

In  estimating  the  hospital  needs  of  a  large  community,  however,  it  would 
not  be  safe  to  expect  a  percentage  of  utilization  of  hospital  beds  as  a  whole 
throughout  the  year  to  be  more  than  75  per  cent,  at  the  present  time,  even 
in  the  face  of  a  general  shortage  of  beds  with  consequent  increase  of  pressure. 
The  Survey  has  sought  to  point  out  the  necessary  inflexibilities  of  hospital 
arrangements  and  the  irregularity  of  demand  throughout  the  year  to  account 
for  this  seeming  inconsistency. 

On  the  map  on  page  823  are  shown  the  eight  "Health  Districts"  used  by 
the  Cleveland  Division  of  Health  for  administration  purposes.  The  hos- 
pital population  of  the  city  on  the  two  census  days  was  tabulated  with  refer- 
ence to  location  of  residence  of  the  patients  according  to  these  health  dis- 
tricts. Comparison  with  the  map  will  assist  in  interpreting  Table  III  in  the 
Appendix  which  gives  this  tabulation. 

A  glance  at  this  table  and  at- the  map  shows  that  the  hospitals  of  the  city 
have  not  been  located  according  to  any  general  plan,  nor  to  any  great  extent 
with  reference  to  the  needs  of  any  particular  locality.  Thus  District  II  and 
District  VIII  show  the  largest  proportion  of  cases  in  the  hospitals, 
and  this  is  what  one  might  expect  considering  the  congested  residential 
character  of  District  VIII,  and  also  the  enormous  business  and  industrial 
population  of  District  II,  during  the  working  hours.  A  large  amount  of 
need  for  hospital  attention  invariably  arises  under  such  conditions,  yet  the 
only  hospital  in  District  II  is  Huron  Road,  and  the  district  has  less  than 
one-third  the  number  of  beds  per  thousand  of  population  that  are  provided 
in  Health  District  III,  which,  with  three  t:mes  the  proportion  of  beds  ac- 
cording to  population,  shows  less  than  one-third  the  number  of  hospital 
cases  per  thousand.     Comparison  with  District  VII  is  also  instructive. 

A  number  of  hospitals  are  found  located  near  the  boundaries  of  districts, 
and  belong  to  the  one  as  much  as  to  the  other,  but  the  more  fundamental 
fact  is  that  the  range  of  service  of  many  hospitals  has  very  little  relation  to 
the  district  in  which  it  is  located.  Table  IV  in  the  Appendix  shows  the 
proportion  of  cases  on  the  first  census  day  registered  in  each  hospital  from 
its  own  health  district. 

Further  study  of  the  individual  hospitals  on  the  second  census  day  and 
in  some  cases  for  other  periods,  showed  quite  clearly  that  hospitals  can  be 
divided  into  two  groups,  with  respect  to  their  range.  One  type,  such  as 
Huron  Road,  Lakeside,  City,  Mount  Sinai,  St.  Luke's,  and  St.  Vincent's, 
have  what  may  be  practically  called  a  city -wide  range.  The  proportion  of 
cases  drawn  from  their  own  vicinity  is  no  larger,  or  is  less  than  one  would 
expect  in  proportion  to  distribution  of  population.  In  the  other  group  are 
hospitals  such  as  Fairview  Park,  St.  John's,  Glenville,  Lutheran,  Provident, 
Grace,  St.  A  n's,  and  St.  Alexis,  which  show  a  large  proportion  of  patients 
drawn  from  the'r  own  vicinity.  The  difference  between  the  two  classes  is 
often  more  striking  when  the  figures  for  the  individual  hospitals  in  the  latter 


83<> 


Hospital  and  Health  Survey 


class  ai:e  examined  in  detail.  In  some  instances  from  two-thirds  to  three- 
fourths  of  the  patients  are  found  to  be  drawn  from  the  hospital's  own  dis- 
trict or  a  neighboring  district,  so  that  the  great  bulk  of  the  hospital  clientele 
is  local.  Generally  speaking,  the  range  of  the  larger  hospitals  is  wider  than 
the  range  of  the  smaller  ones. 

The  facts  shown  in  these  tables  are  of  importance  in  connection  with  the 
location  of  future  hospital  units,  and  will  be  referred  to  later  in  that  connec- 
tion in  the  section  on  Community  Planning. 

It  is  important  that  each  board  of  trustees  understand  the  range  of  its 
own  hospital.  Adaptation  to  the  special  needs  of  its  clientele  is  a  very 
different  matter  in  a  hospital  which  serves  primarily  its  neighborhood  from 
the  case  of  one  which  draws  from  all  over  the  city  and  from  the  environs. 

The  most  important  summary  conclusion  to  which  the  data  in  this  sec- 
tion lead  is  the  shortage  of  1,500  hospital  beds  in  Cleveland  in  1920.  The 
work  of  the  existing  hospitals  has  been  unduly  limited,  because  of  this  short- 
age, to  urgent  surgical  and  to  maternity  cases.  Medical  and  special  work, 
particularly  for  children,  has  not  been  provided  for  in  any  adequate  degree. 
Study  of  the  Cleveland  hospitals  reveals  these  conditions  quite  clearly,  and 
they  are  thrown  into  relief  by  comparisons  made  with  Xew  York  and  Boston. 
It  is  apparent  that  while  the  best  administered  hospitals  of  Cleveland  have 
used  their  beds  to  as  full  capacity  as  the  best  institutions  elsewhere  with  which 
comparisons  have  been  made,  the  hospitals  in  Cleveland  as  a  whole  have  fallen 
below  a  desirable  percentage  of  utilization  of  their  theoretical  capacity,  even 
in  the  face  of  the  community's  need  for  beds.  Some  of  the  reasons  for  this 
have  been  indicated,  and  the  need  for  flexibility  and  efficient  administration 
has  been  pointed  out  as  a  remedy. 


,«fl      NlORl__8£O.S 


«ow 

Fig.  II. 
Provision  and  Need  for  Ilosjnta    Rens 


Hospitals  and  Dispensaries  837 


Distribution  of  hospitals  according  to  sections  of  the  city  shows  lack 
in  the  past  of  any  general  planning  and  the  need  for  the  formulation  of  prin- 
ciples by  which  the  locations  and  functions  of  future  hospitals  can  be  de- 
termined. It  is  apparent  that  there  is  special  need  and  large  demand  for 
hospital  service  coming  from  the  central  section  of  the  city,  and  inasmuch  as 
a  considerable  part  of  the  need  from  this  section  is  known  to  be  of  an  urgent 
character,  future  plans  for  the  location  of  hospitals  must  take  into  con- 
sideration local  provision  for  this  central  section. 

It  has  been  sought  in  this  section  to  point  out  not  only  general  matters 
of  interest  to  the  city  as  a  whole,  but  to  indicate  some  of  the  kinds  of  facts 
which  hospitals  need  to  know  about  themselves;  which  the  trustees  and 
their  representatives  should  have  periodically  reported  to  them.  In  how 
many  hospitals  do  the  monthly  reports  to  the  trustees  show,  for  instance,  the 
percentage  of  beds  used  in  each  of  the  main  divisions  of  the  hospital  in  pro- 
portion to  the  theoretical  capacity  of  each  division?  Shrewd  business  men 
know  just  what  facts  to  demand  in  regular  reports  from  their  own  enter- 
prises so  that  they  shall  be  able  to  determine  whether  or  not  the  business 
is  well  run.  Trustees  should  be  as  discriminating  in  the  selection  of  the  facts 
which  they  ask  to  have  set  up  as  the  guideposts  for  the  business  and  policy 
of  their  hospitals. 


83S  Hospital  and  Health  Survey 


ORGANIZATION  FOR  SERVICE 

A  hospital  is  much  more  complex  than  most  business  organizations  of 
equivalent  size.  Its  peculiarity  is  the  inclusion  of  a  number  of  different  pro- 
fessions, each  highly  specialized,  which  must  work  together  and  which  must 
be  kept  in  effective  working  relations.  The  basis  of  a  hospital  is  its  medical 
staff,  but  in  addition  to  this  medical  element,  is  the  business  administration, 
represented  by  the  business  men  of  the  trustees,  by  the  superintendent^  and 
by  his  administrative  assistants;  the  nurses,  another  highly  specialized  and 
well  organized  group;  social  service,  representing  still  another  and  different 
type  of  work  in  the  hospital;  and  finally,  the  housekeeping,  mechanical,  and 
clerical  groups,  who  maintain  the  essential  daily  routine  of  the  plant.  It 
should  be  added  that  while  the  emphasis  of  the  work  of  most  superinten- 
dents is  on  the  business  side,  the  superintendent  ought  to  interpret,  develop 
and  represent  all  phases  of  a  hospital's  activity. 

Hospital  personnel  thus  includes  such  widely  varying  elements  and 
draws  them  into  such  intimate  relationship  that  the  successful  organization 
and  administration  of  a  modern  hospital  is  a  difficult  matter  requiring  special 
training  and  skill.  There  are  stated  at  the  end  of  this  chanter  a  series  of 
recommendations  regarding  hospital  organization  to  which  the  discussion  of 
this  chapter  aims  to  lead,  and  which  it  endeavors  to  interpret. 

The  basis  of  hospital  organization  may  be  one  of  three  types.  The 
first,  which  is  found  only  in  the  proprietary  hospital,  is  a  group  of  stock- 
holders or  owners  of  the  hospital  corporation,  who  may  or  may  not  have  an 
interest  in  the  professional  and  welfare  activities  of  the  institution.  The 
second  type,  as  represented  by  City  Hospital,  is  under  the  direction  of  a 
single  man,  the  Director  of  Pub  ic  Welfare,  who  appoints  the  executive 
officer  and  staff  of  the  hospital.  The  third  type,  the  usual  form  of  organiza- 
tion of  privately  supported  hospitals,  is  that  of  a  board  of  trustees.  Cer- 
tain hospitals  which  are  under  the  control  of  religious  organizations  fall 
somewhere  midway  between  types  two  and  three. 

It  is  proper  enough  that  there  exist  proprietary  hospitals  as  a  form  of 
business  enterprise  meeting  an  apparent  public  demand,  but  no  hospital 
which  aims  to  be  in  the  public  service  class  can  expect  to  receive  public  con- 
fidence and  support  unless  it  has  as  its  governing  authority  an  individual 
or  group  possessing  the  point  of  view  of  public  service,  without  financial 
interest  in  the  operations  of  the  institution. 

The  conditions  found  in  the  City  Hospital  of  Cleveland  indicate  very 
clearly  the  need  for  more  general  public  interest  in  an  institution  of  major 
importance,  such  as  this.  The  most  serious  administrative  deficiency  found 
at  the  City  Hospital  by  the  Survey  was  in  the  nursing  service.  So  great  a 
shortage  of  nursing  service  was  found  that  the  conditions  amount  to  a  serious 
neglect  by  the.  city  of  its  solemn  responsibility  for  the  humane  care  of  sick 
and  helpless  citizens.  It  is  recognized  that  the  ultimate  responsibility  rests 
with  the  fitizens  of  Cleveland,  who  should  have  approoriated  more  money  for 
the  maintenance  of  City  Hospital.    More  immediately,  the  responsibility  rests 


Hospitals  and  Dispensaries  830 

with  the  appropriating  authorities  of  the •  Cleveland  municipal  administra- 
tion.* The  executive  officers  of  the  Department  of  Public  Welfare  and  the 
City  Hospital  should  be  held  responsible  for  voicing  the  need  in  a  clear, 
effective,  and  persistent  way,  both  to  the  appropriating  authorities  and  to 
the  public.  There  is  not  evidence  that  sufficient  attention  has  been  called 
to  the  conditions  by  the  administrative  officials  who  have  been  aware  of 
them. 

In  the  nursing  service  of  City  Hospital  a  decided  shortage  of  students 
exists,  and  in  some  instances,  of  the  supervising  staff  also.  It  is  a  conserva- 
tive estimate  that  there  are  only  about  one-third  as  many  students  as  are 
needed  for  the  number  of  patients,  as  63  students  are  assigned  the  481  beds 
used  for  training — a  ratio  of  one  student  to  7  or  8  beds.  The  ratio  of  students 
to  beds  was  in  actual  practice  lower  than  this — one  student  to  10  beds  in  the 
general  services  during  the  day,  and  one  student  to  40  beds  at  night.  Due 
to  the  shortage  of  student  nurses,  ward  attendants  have  had  nursing  duties 
assigned  to  them  for  which  they  were  entirely  unqualified. 

The  presence  of  a  board  of  trustees  or  cf  a  visiting  committee  who  were 
actively  interested  in  the  hospital  might  probably  have  been  of  great  service 
to  the  administrative  officers  of  the  hospital  and  to  the  Director  of  Public- 
Welfare  in  making  apparent  to  the  municipal  administration  and  to  the 
general  public  the  neecis  of  the  City  Hospital  and  the  gravity  of  the  present 
deficiency.  As  the  Survey  has  recommended,  an  appropriation  of  $150,000 
a  year  for  nursing  service  is  necessary  for  at  least  the  next  year  or  two  in 
order  to  secure  a  sufficient  number  of  graduate  nurses  to  provide  a  minimum 
of  satisfactory  care  for  the  patients.  If,  as  the  Survey  has  also  recommended, 
a  sufficiently  capable  head  of  the  training  school  can  be  secured  with  an  ade- 
quate corps  of  trained  assistants,  it  is  probable  that  the  training  school 
can  be  so  built  up  that  the  amount  just  mentioned  can  be  diminished  in 
future  years,  as  an  increased  number  of  student  nurses  is  received,  up  to  the 
maximum  for  which  the  hospital  can  provide  suitable  training. 

At  Warrens ville  Infirmary  the  lack  of  medical  and  attendant  service  is 
also  grave,  and  here  again  the  institution  has  been  lost  si^ht  of,  even  by 
sections  of  the  public  which,  if  they  knew  the  fact's,  would  be  interested  to 
arouse  public  opinion  to  better  conditions.  The  need  is  not  only  for  more 
medical  staff  and  attendants  at  Warrensville,  but  also  for  recreational  facili- 
ties for  old  people  and  others  who  are  patients  and  who  need  some  element 
in  their  lives  beyond  the  barest  minimum  of  physical  care;  also  for  the  em- 
ployed help  of  the  institution,  who,  particularly  under  present  economic- 
conditions,  are  obtained  with  difficulty  in  a  place  which  is  relatively  isolated 
in  comparison  with  other  places  in  which  as  good,  if  not  better,  wages,  can 
be  secured.  Much  in  this  direction  would  gladly  be  done  by  volunteer 
assistance  if  the  right  people  knew  the  facts  and  were  interested  to  be  active 
in  the  matter. 

It  has  been  recommended  by  the  Survey  that  the  Cleveland  City  Hos- 
pital be  governed  by  a  board  of  trustees,  which  would  require  a  change  in  the 

*It  is  recogrrzed  that  legal  restrictions  upon  municipal  taxing  power  have  placed  considerable 
imitations  upon  Cleveland's  expenditures  for  public  services,  as  in  many  other  cities. 


840  Hospital  and  Health  Survey 

city  charter.  It  may  be  pointed  out  that  from  the  standpoint  of  efficiency, 
government  by  a  director  need  in  no  way  suffer  in  comparison  with 
government  by  a  board  of  trustees.  The  effectiveness  of  either  form  of 
government  depends  upon  personnel,  the  recommendation  in  favor  of  a  board 
of  trustees  being  chiefly  that  of  greater  stability  through  changing  municipal 
administrations.  This  again  may  work  for  good  or  ill,  depending  upon  per- 
sonnel. At  some  periods  it  would  serve  to  retard  progress,  and  in  others  to 
prevent  disruption  following  a  political  overturn.  On  the  whole,  however,  a 
board  of  trustees  is  desirable. 

Even  under  the  most  ideal  conditions  of  municipal  administration,  a  city 
hospital  needs  to  be  brought  in  contact  with  its  community,  and  this  can 
best  be  secured  by  attaching  to  the  institution  in  some  way  a  group  of  dis- 
interested citizens,  men  and  women,  who  will  visit  it,  be  in  touch  with  its 
work,  help  its  governing  and  executive  officers  by  friendly  advice,  and  above 
all  else,  interpret  the  institution,  its  work,  and  its  needs  to  the  financial 
appropriating  authorities  and  to  the  public  as  a  whole.  The  formation  of  a 
strong  board  of  trustees  best  accomplishes  these  purposes,  but  if  this  pro- 
posal proves  unacceptable,  some  progress  toward  the  same  result  may  be 
accomplished  by  a  properly  selected  visiting  or  auxiliary  committee, 
appointed  by  the  Director  of  Public  Welfare;  such  a  committee 
of  course  having  only  advisory  powers.  The  degree  to  which  such  a  board 
will  be  of  practical  service  will  depend  almost  entirely  upon  the  Director. 
He  has  it  in  his  power  to  stimulate  the  board  to  activities  which  will 
not  interfere  with  the  hospital's  activities  but  be  of  benefit,  or,  on  the  other 
hand,  he  may  reduce  the  group  to  one  on  which  few  capable  individuals  will 
find  interest  in  serving.  In  the  absence  of  a  board  of  trustees,  however,  the 
presence  of  some  such  advisory  body  is  highly  advisable. 

A  hospital  which  is  managed  by  a  religious  sisterhood  will  do  well,  as 
four  such  hospitals  in  Cleveland  have  recently  done,  to  appoint  a  lay  advis- 
ory committee  which  will  exercise  much  the  same  functions  as  a  board  of 
trustees  though  without  the  legal  authority  usually  vested  in  them  in  other 
hospitals. 

For  the  typical  hospital,  privately  incorporated,  there  should  unques- 
tionably be  a  board  of  trustees.  Such  bodies  are  usually  either  self-perpet- 
uating or  elected  by  a  hospital  membership  or  by  church  or  other  organiza- 
tions which  constitute  the  hospital  corporation.  Members  of  boards  should 
have  definite  terms,  and  the  personnel  should  change  slowly,  a  few  terms 
expiring  each  year.  Many  of  the  chief  deficiencies  in  hospital  administration 
in  Cleveland  and  elsewhere  have  arisen  because  of  defects  in  the  make-up 
of  the  board  of  trustees  or  in  its  relationship  to  other  groups  in  the  hospital 
organization.  The  composition  of  boards  of  trustees  has  too  frequently 
been  determined  by  an  historical  accident  which  threw  together  a  group  of 
doctors  and  lay  business  men  who  together  made  up  the  original  body,  or 
on  the  other  hand  the  board  is  composed  entirely  of  business  men,  who  are 
usually  immersed  in  affairs,  and  leave  to  the  medical  staff  or  to  one  or  two 
of  their  own  number,  practically  the  whole  responsibility  for  administration 
of  the  institution. 


Hospitals  and  Dispensaries  841 

Perhaps  the  most  frequent  cause  of  difficulty  in  Cleveland  has  been  the 
existence  of  a  number  of  different  boards  or  groups  within  the  same  hospital, 
without  clear  definition  of  their  respective  powers  and  duties.  Thus  there 
may  be  found  a  board  of  trustees,  a  board  of  managers,  and  an  auxiliary 
board  in  the  same  institution.  The  personnel  of  one  of  these  groups  may 
be  entire1  y  women;  of  another,  entirely  men;  the  third  may  be  also  of  women, 
or  of  both  men  and  women.  The  original  reason  for  the  formation  of  these 
different  bodies  was  obviously  the  desire  to  interest  as  many  persons  as  pos- 
sible in  the  hospital  for  the  sake  of  moral  and  financial  support.  Principles 
of  organization  applicable  to  hospitals  as  well  as  to  business  establishments 
require  that  there  shall  be  one  governing  authority.  The  existence  of  other 
boards  or  committees  is  not  inconsistent  with  this  principle,  but  the  pro- 
visions of  the  by-laws  and  the  actual  practice  of  the  hospital  should  make 
it  quite  clear  that  a  single  body  which  should  be  known  in  general  as  the 
"Board  of  Trustees"  has  complete  authority*,  and  that  all  other  commit- 
tees or  groups  have  advisory  powers  or  delegated  powers  only;  nor  should 
powers  be  delegated  by  the  board  save  to  committees  which  include  some  of 
its  own  membership.  Delegation  of  power  to  other  committees  almost 
invariably  leads  to  division  of  authority  and  confusion  in  administration. 

In  a  few  hospitals  where  numbers  of  different  boards  and  committees 
exist,  a  simple  remedy  is  practical — consolidation.  There  are  usually  found 
a  certain  number  of  active  members  within  each  committee,  just  about 
enough  altogether  to  make  a  single  effective  governing  body. 

A  board  of  trustees  of  a  hospital  ought  to  include  within  itself  all  the 
chief  elements  with  which  the  hospital  is  concerned.  Boards  frequently 
suffer  from  being  composed  entirely  of  business  men.  Boards  of  trustees 
should  include  other  elements  which  enter  deeply  into  the  work  of  a  hospital. 
Education  is  one  of  a  hospital's  interests,  in  relation  to  nurses,  to  medical 
study,  and  to  the  community  in  general  along  health  lines.  Every  hospital, 
particularly  those  connected  with  medical  schools  or  maintaining  training- 
schools  for  nurses,  should  include  in  their  boards  one  or  more  persons  inter- 
ested in  or  connected  with  educational  activities.  Men  and  women  concerned 
in  the  philanthropic  and  social  service  relations  of  a  hospital  likewise  repre- 
sent an  element  which  ought  to  be  on  every  hospital  board.  Selection  of 
personnel  from  the  business,  educational,  philanthropic,  and  other  elements 
which  ought  together  to  make  up  the  circle  of  interests  of  a  hospital  is  no 
easy  task,  for  the  group  as  a  whole  must  not  be  too  large,  it  must  be  har- 
monious, and  must  be  capable  of  prompt  and  effective  action.  Such  mingling 
of  interests  in  the  personnel  of  a  board  is  a  goal  to  be  sought  for.  Men 
experienced  in  the  management  of  business  affairs  constitute  a  necessary  and 
valuable  element,  but  men  and  women  interested  and  concerned  with  other 
activities  need  to  be  sought  for  and  included. 

It  is  perhaps  not  quite  clear  to  the  average  person  why  the  physicians 
who  do  the  medical  work  of  a  hospital  should  not  be  members  of  its  board  of 
trustees.     The  accumulated  experience  of  hospitals  throughout  the  country 

*  It  is  well  to  restrict  the  use  of  the  word  "Board"  to  this  one  body,  and  to  use  the  term  "com- 
mittee" for  all  other  groups,  medical  and  lay. 


842  Hospital  and  Health  Survey 


is  against  such  membership.  The  physician  who  is  on  a  hospital  staff  or 
who  is  in  active  practice  will  have,  if  a  member  of  the  board  of  trustees,  a 
double  position  and  a  double  interest.  The  word  double  is  not  to  be  inter- 
preted as  meaning  selfish.  As  a  member  of  the  board,  the  physician  is  in  a 
position  of  authority  over  the  hospital  policies.  As  a  member  of  the  staff, 
he  is  connected  with  the  conduct  of  a  definite  piece  of  work — carrying  out 
these  policies  within  the  hospital.  So  long  as  hospital  staffs  are  made  up 
of  practising  physicians,  each  of  whom  gives  a  portion  of  his  time  to  the  hos- 
pital service,  the  selection  of  a  few  of  these  men  for  membership  on  the  board 
of  trustees  is  certain  to  create  difficulties.  The  medical  knowledge  and  in- 
terest of  the  physician  is  the  professional  guide  to  which  the  board  of  trus- 
tees must  give  attention,  but  this  guidance  from  the  medical  staff  can  best 
be  furnished  through  the  medical  staff's  own  organization,  acting  as  a  pro- 
fessional body  and  related  to  the  board  through  a  suitable  committee  and 
through  the  superintendent. 

The  nursing  work  of  a  hospital  is  another  element  of  great  importance  in 
the  daily  administration  of  the  hospital,  and  one  which  at  the  present  time 
presents  especial  difficulties.  A  special  section  of  the  report  of  the  Cleveland 
Hospital  and  Health  Survey  is  devoted  entirely  to  nursing  (Part  IX.)  Here  it 
may  be  mentioned  merely  that  the  relation  between  the  nurse  and  the  hos- 
pital administration  in  the  past  has  been  largely  through  the  nurses'  train- 
ing school.  As  the  nursing  report  shows,  hospitals  have  been  too  ready  to 
utilize  their  training  school  for  nurses  as  a  means  of  securing  cheap  labor. 
Part  of  the  young  woman's  payment  for  receiving  education  in  nursing  has 
been  rendered  by  giving  manual  service.  Nurses  are  too  much  in  demand 
to  permit  these  conditions  to  continue.  While  part  of  the  education  of  a 
nurse  lies  necessarily  in  the  hospital  and  dispensary,  where  practical  ex- 
perience must  be  gained,  the  education  of  the  future  nurse  and  the  daily 
conduct  of  the  hospital  routine  cannot  be  identified  so  closely  in  the  future 
as  they  have  been  in  the  past.  The  education  of  nurses  must  stand  in  a 
greater  measure  on  its  own  feet,  as  an  educational  enterprise,  affiliated  with 
the  hospital  more  along  the  lines  of  the  affiliation  between  medical  school 
and  hospital.  The  routine  work  in  caring  for  patients  must  be  conducted 
in  a  larger  measure  by  women  who  have  already  had  their  educational  train- 
ing for  the  work,  and  who  do  not  receive  an  educational  course  as  part  of 
their  compensation.  The  varied  activities  which  have  been  carried  out  in 
the  past  by  the  graduate  nurse  and  the  pupil  nurse  must  in  the  future  be 
conducted  by  an  apportionment  of  tasks  among  graduate  nurses,  attendants, 
maids,  and  orderlies. 

In  its  relation  to  hospital  organization,  this  may  mean  physical  separa- 
tion between  the  training  school  and  hospital  in  many  instances,  as  out- 
lined in  the  nursing  report.  The  conduct  of  training  schools  by  hospitals 
as  part  of  their  own  organization  requires  special  knowledge  and  usually  a 
special  committee,  in  order  that  educational  policies  may  be  developed,  and 
educational  standards  maintained.  For  these  reasons,  the  special  training 
school  committee  recommended  in  the  plan  of  organization  is  deemed  de- 
sirable. The  relationship  proposed  between  the  trustees,  the  training 
school  committee,  the  superintendent  of  the  hospital,  and  the  head  of  the 
nursing  service,  should  be  considered  carefully. 


Hospitals  and  Dispensaries  843 

The  social  service  department  represents  the  newest  element  to  enter 
the  hospital,  and  its  position  as  yet  has  not  received  universal  recognition. 
In  a  number  of  the  best  institutions,  however,  in  Cleveland  and  elsewhere, 
the  social  service  department  is  developed  and  its  place  is  fairly  well  defined. 
Few  boards  of  trustees  and  few  superintendents  have  at  the  present  time 
sufficient  knowledge  concerning  the  policies  and  the  methods  that  should 
prevail  in  a  social  service  department  to  be  able  to  guide  it  properly.  A 
special  social  service  committee  is  therefore  thought  desirable,  to  serve  with 
advisory  powers  only,  and  to  help  in  developing  the  social  service  of  the 
hospital  so  as  to  be  of  the  maximum  assistance  to  its  medical  work. 

A  failure  on  the  part  of  the  board  of  trustees  to  give  sufficient  authority 
to  their  executive  officer,  the  superintendent,  is  another  source  of  weakness 
in  not  a  few  hospitals  in  Cleveland  as  elsewhere.  More  than  one  executive 
head  in  an  organization  is  an  obvious  weakness  and  danger.  To  manage 
a  modern  hospital  with  all  of  its  varied  interests  and  all  the  widely  differing 
groups  within  its  personnel,  requires  a  man  or  woman  of  unusual  ability  and 
tact,  and  with  special  training.  Everywhere  in  the  country  the  number  of 
such  qualified  persons  is  at  present  far  below  the  demand.  The  board  and 
its  advisory  committees  need  to  supplement  the  superintendent  in  advisory 
as  well  as  in  directing  ways.  It  will  be  observed  that  according  to  the  plan 
for  hospital  organization  outlined  in  the  following,  the  superintendent  stands 
in  a  central  position,  meeting  with  the  board  on  the  side  of  hospital  adminis- 
tration', and  with  the  medical  executive  committee  on  the  side  of  the  hos- 
pital's professional  activities. 

A  third  aspect,  which  is  not  mentioned  in  the  plan  of  organization,  but 
which  may  be  taken  for  granted,  is  the  superintendent's  relation  to  his 
administrative  departments;  the  steward,  the  dietitian,  the  engineer,  as  well 
as  the  head  of  the  nursing  and  of  the  social  service  departments.  Periodical 
conferences  between  the  superintendent  and  the  administrative  group  are 
desirable.  Medical,  nursing,  social,  and  administrative  interests  within  the 
hospital  render  it  desirable  that  from  time  to  time  representatives  of  all  the 
different  groups  be  brought  together  for  their  better  mutual  understanding. 
Recommendation  number  6  points  in  this  direction.  It  is  particularly  im- 
portant that  members  of  the  board  of  trustees  shall  understand  personally 
the  hospital  inter-relationships  and  the  different  parts  of  its  work,  and  that 
they  shall  come  into  contact  at  first-hand  with  sources  of  information. 
Through  such  conferences  held  from  time  to  time  for  the  discussion  of  selected 
problems,  this  can  be  achieved.  There  is  no  stimulus  to  members  of  a 
managing  board  like  direct  contact  with  facts  and  with  the  people  who  are 
doing  the  work  over  which  they  have  authority. 

''What  is  the  whole  duty  of  a  Trustee?"  is  perhaps  the  fundamental 
question  concerning  hospital  organization.  How  is  a  man  or  woman  living 
in  a  great  city  and  with  business  or  other  definite  vocation,  to  give  sufficient 
time  to  a  hospital  really  to  understand  its  work  and  to  be  able  to  meet  to 
the  full  the  responsibilities  of  trusteeship?  The  question  cannot  be  answered 
in  general  terms,  for  the  activities  of  a  modern  hospital  are  so  varied  and  so 
technical  that  few  members  can  come  into  sufficient  touch  with  all  of  them 
to  have  sound  judgment  upon  all  questions  that  may  arise  regarding  any 


844  Hospital  and  Health  Survey 

one  of  them.  Yet,  by  division  of  labor  among  the  members  of  a  board,  and 
above  all,  by  a  really  active  sense  of  responsibility  made  effective  through 
the  leadership  of  the  president  or  other  officers,  a  reasonable  degree  of  knowl- 
edge of  the  work  of  the  hospital  can  be  gathered  by  each  member,  and  the 
sum  total,  when  the  board  gathers  together,  will  be  sufficient  to  render 
the  trustees  a  truly  responsible  governing  body. 
•j 
It  is  of  particular  importance  that  the  trustees  understand  what  facts 
they  should  know  of  periodically,  so  that  these  may  be  presented  in  the 
monthly  and  annual  reports  of  the  superintendent.  The  percentage  of  beds 
used  in  each  division  of  the  hospital  has  already  been  mentioned  as  one  of 
these  important  facts.  The  length  of  stay  of  cases  in  the  different  divisions 
of  the  hospital  is  another.  At  the  time  of  the  Survey  census,  it  was  found 
that  taking  the  general  hospitals  of  Cleveland  as  a  whole,  44.6  per  cent,  of 
the  patients  had  at  that  time  been  in  the  hospital  from  three  to  fourteen 
days,  13.2  per  cent,  had  been  in  the  hospital  less  than  three  days,  19.2  per 
cent,  between  fourteen  and  thirty  days,  9.2  per  cent,  between  one  month 
and  two  months,  and  12.9  per  cent,  more  than  two  months  (9%  not  stated). 
The  proportion  of  cases  staying  for  these  longer  periods  is  higher  than  it 
should  be  in  hospitals  designed  primarily  for  acute  stages  of  disease.  The 
reason  lies  largely  in  the  lack  of  dispensaries  and  of  facilities  for  convalescent 
and  chronic  patients  in  Cleveland,  to  which  attention  will  be  devoted  later 
in  this  report.  A  study  of  individual  hospitals  showed  wide  variations  in  this 
figure,  ranging  from  no  patients  staying  over  sixty  days  to  as  high  as  29.9 
per  cent.  A  report  showing  the  length  of  time  that  patients  have  been  in 
the  hospital,  and  the  number  in  the  various  divisions  of  the  hospital  who 
had  been  there  more  than  a  normal  period,  should  be  of  distinct  value  to  the 
trustees  as  well  as  to  the  medical  staff  and  the  superintendent. 

Statistical  record  of  patients  who  have  been  refused  admission  is  another 
item  of  significance.  Monthly  reports  should  show  the  number  of  refused 
cases,  classified  by  the  main  type  of  case,  i.  e.,  medical,  surgical,  children's, 
etc.,  and  classified  also  according  to  whether  the  applicant  was  for  a  pay, 
part-pay,  or  free  bed,  and  with  classification  according  to  reasons  for  re- 
jection. Not  a  few  hospitals  fail  to  keep  any  memorandum  of  cases  refused 
admission  because  of  lack  of  room  or  other  reasons.  Data  as  to  whether 
or  not  a  waiting  list  is  maintained,  or  whether  refused  cases  are  placed  on 
the  waiting  list,  are  also  of  value,  although  the  maintenance  of  a  waiting  list 
is  not  always  practicable. 

Statistics  regarding  the  results  of  care  have  been  developed  somewhat 
through  the  American  College  of  Surgeons,  but  their  further  development 
and  the  regular  reporting  of  the  condition  of  patients  at  discharge  and  at 
specified  periods  thereafter  should  be  part  of  the  regular  reports  of  hospitals 
in  the  future.  Similarly  in  dispensaries,  the  trustees  should  know  what 
proportion  of  patients  pay  one  visit  and  never  come  back  to  continue  needed 
treatment. 

Those  items  are  mentioned  here  merely  as  illustrations  and  of  course  are 
in  addition  to  the  ordinary  statistics  of  the  number  of  patients  admitted,  the 
number  of  units  of  work  done  in  each  of  the  chief  divisions,  and  the  financial 


Hospitals  and  Dispensaries  845 

figures  showing  income  and  expenditures  for  the  various  departments  of  the 
institution.  In  the  section  on  individual  hospital  planning  we  shall  return 
to  this  subject  and  summarize  the  more  essential  facts  which  a  hospital  or 
dispensary  should  gather  and  present  regularly  for  the  information  of  its 
governing  body,  its  supporters  and  the  public.  To  substitute  guidance  by 
facts  for  guidance  by  impressions  and  by  hearsay  is  the  goal  of  the  best  ad- 
ministration. 

Summary  of  Principles  of  Hospital  Organization* 

1.  The  final  governing  authority  of  the  hospital  should  be  a  Board  of 
Trustees.  No  member  of  the  Board  should  be  a  member  of  the  active  or 
consultant  medical  staff  of  the  hospital.  Hospitals  which  are  under  a  re- 
ligious or  public  city  or  federal  organization  and  which  therefore  cannot 
have  Trustees,  should  appoint  an  Advisory  Committee  similarly  constituted. 
In  addition  to  the  men  members  of  the  Board  of  Trustees  who  represent 
chiefly  financial,  administrative  and  broad  public  interests  and  experience 
it  is  of  much  importance  that  there  be  included  on  the  Board  of  Trustees  a 
representative  of  some  institution  of  higher  education,  viz:  University,  Nor- 
mal College  and  women  members  whose  experience  and  interest  can  be  relied 
upon  to  contribute  constructive  ideas  and  opinions. 

2.  The  appointment  of  the  medical  staff  should  be  vested  in  the  Board 
of  Trustees.  All  members  of  the  staff,  chiefs  of  services,  or  assistants  should 
be  appointed  by  the  Board  for  terms  of  one  year  renewable  by  the  Board. 
The  nomination  should  be  made  on  the  initiative  of  the  Board  of  Trustees 
or  of  the  Medical  Staff  or  of  an  executive  committee  of  the  medical  staff. 
The  Board  of  Trustees  should  consult  with  the  Superintendent,  or  Chief 
Executive  Officer,  before  confirming  the  nomination  of  a  Medical  Staff,  or  of 
i  ndividual  members  thereof. 

3.  The  Superintendent  of  the  hospital  should  be  appointed  by  the  Board 
He  should  have  entire  administrative  authority  over  all  departments  of  the 
hospital.  Under  the  rules  and  regulations  adopted  by  the  Board  of  Trus- 
tees, the  Superintendent  of  the  hospital  should  have  authority  to  nominate 
or  appoint  all  heads  of  departments  and  employes.  This  implies  the  au- 
thority for  discharge  or  dismissal  of  any  employe  for  cause.  The  superin- 
tendent should  be  the  representative  of  the  trustees  in  relation  to  the  staff 
or  outside  interests. 

4.  The  medical  staff  should  be  definitely  organized  for  the  promotion  of 
team  work,  common  policies  and  satisfactory  relations  with  the  administra- 
tion of  the  hospital.  Regular  meetings  of  the  medical  staff  or  sections 
thereof  should  take  place  for  the  discussion  of  professional  work.  For 
guidance  in  organizing  such  professional  conferences  the  recommendations  of 
the  American  College  of  Surgeons  are  called  to  the  attention  of  the  medical 
staffs  of  hospitals.  The  staff  should  be  organized  into  divisions  or  services, 
medical,  surgical,  etc.  It  is  desirable  that  there  be  a  recognized  chief  for 
each  division. 

*  Prepared  in  collaboration  with  Haven  Emerson,  M.  D.,  Director  of  the  Survey,  and  W.  L.  Bab- 
cock,   M.  D.,  consultant  on  Hospital  Administration. 


846  Hospital  and  Health  Survey 

(a)  Provision  should  be  made  in  the  By-laws  of  the  Hospital  for  the 
recognition  of  physicians,  not  members  of  the  staff,  whose  practice  in  the 
hospital  complies  with  definite  hospital  standards.  It  is  recommended  that 
these  physicians  organize  into  an  auxiliary  staff,  without  service  or  voting 
power,  and  that  a  delegate  or  delegates  from  this  staff  be  recognized  by  the 
Trusteesj  and  Attending  Staff  as  their  representative. 

5.  There  should  be  a  Medical  Executive  Committee  composed  of  mem- 
bers of  the  medical  staff,  selected  by  the  medical  staff  or  by  the  Board  of 
Trustees  on  the  nomination  of  the  medical  staff.  The  Superintendent  of 
the  Hospital  should  be  a  member  of  this  Committee.  The  total  member- 
ship of  the  Committee  should  not  be  so  large  as  to  be  unwieldy.  Seven 
members  is  generally  the  maximum  desirable. 

6.  It  is  recommended  that  the  Board  of  Trustees  of  hospitals  arrange  for 
periodica]  conferences  of  designated  members  of  the  trustees,  of  the  medical 
executive  committee,  the  superintendent  and  administrative  officers  such  as 
the  heads  of  the  training  school  or  nurses'  service,  and  of  the  social  service 
department.  This  joint  group  should  meet  periodically  for  the  discussion 
of  hospital  policies  or  administrative  matters. 

7.  The  staff  of  the  dispensary  or  out-patient  department  should  be  ap- 
pointed according  to  the  principles  above  laid  down  and  the  physicians 
serving  in  the  dispensary  should  receive  definite  recognition  as  members  of 
the  hospital  organization  and  staff.  For  each  department  of  the  dispensary 
there  should  be  designated  a  chief  of  clinic  who  should  be  under  the  general 
authority  of  the  chief  of  the  corresponding  department  of  the  hospital,  but 
who  should  be  directly  consulted  by  the  superintendent  or  the  assistant 
superintendent  who  is  in  charge  of  the  dispensary  on  all  matters  affecting 
the  dispensary.  The  chiefs  of  the  dispensary  service  should  constitute  a 
Dispensary  Medical  Committee  which  with  the  superintendent,  the  assistant 
executive  in  charge  and  such  others  as  may  be  designated  should  meet  from 
time  to  time  on  dispensary  matters.  It  is  suggested  that  a  representative 
of  the  dispensary  staff  be  a  member  of  the  Medical  Executive  Committee. 

8.  The  medical  staff  of  the  hospital  acting  thru  the  Medical  Executive 
Committee  and  the  Superintendent  should  formulate  a  definite  set  of  stand- 
ards, subject  to  ratification  by  the  Trustees,  for  all  professional  work  of  phy- 
sicians in  the  hospital  touching  such  matters  as  attendance,  the  making 
and  supervision  of  records,  diagnosis,  use  of  laboratories,  X-Ray  and  other 
diagnostic  aids,  the  duties  of  residents  and  internes,  the  inter-relation  of 
staff  physicians  and  outside  physicians,  the  matter  of  fee-splitting,  etc. 

9.  Physicians  not  members  of  the  hospital  staff  should  be  entitled  to 
send  to  the  hospital  and  to  treat  therein  private  cases  in  rooms  or  wards, 
subject,  however,  to  such  limitation  as  to  number  of  beds  to  be  allotted  to 
outside  physicians  as  may  be  formally  made  by  the  Trustees,  and  provided 
that  the  physicians  treating  such  cases  conform  to  all  standards  made  by 
the  Medical  Staff.    " 


Hospitals  and  Dispensaries  847 

10.  No  physician  should  receive  a  fee  from  patients  other  than  such  fees 
as  may  be  permitted  to  staff  physicians  nor  should  any  physician  receive  a 
fee  from  a  patient  unless  the  charges  for  the  hospital  care  have  been  met 
according  to  the  rate  established  for  various  rooms  or  wards  for  members 
of  the  staff  and  outside  physicians  alike. 

11.  In  such  hospitals  as  may  still  continue  to  keep  a  training  school  as 
part  of  the  hospital  organization  there  should  be  appointed  by  the  Board  of 
Trustees  a  training  school  committee  composed  of  both  men  and  women, 
to  direct  educational  policies.  This  committee  should  include  representa- 
tives of  the  Board  of  Trustees,  with  other  persons  known  to  have  had  experi- 
ence in  education,  and  also  members  of  the  alumnae  of  the  nurses'  training 
school.  The  superintendent  of  the  hospital  and  the  director  of  the  train- 
ing school  in  the  hospital  and  representatives  of  the  medical  staff  selected 
by  the  medical  executive  committee,  though  not  members  of  the  training 
school  committee  should  sit  with  the  committee. 

r  Among  the  Catholic  hospitals  or  in  hospitals  administered  under  a  re- 
ligious organization  which  have  no  boards  of  trustees  and  are  subject  to  the 
direction]:  off  the  Bishop  of  the  diocese,  a  committee  on  the  training  school, 
advisory; to! the  Bishop,  might  with  advantage  be  established  at  once  to 
direct  the]educational  policies  of  the  training  school. 

The  relationship  between  schools  of  nursing  and  hospitals  should  be 
essentially  the  same  as  that  created  between  medical  schools  and  hospitals. 
The  School  of  Nursing,  like  the  medical  school,  should  exist  primarily  to  give 
technical  education  to  students  who  are  to  obtain  part  of  their  training  in 
the  hospitals. 

An  ideal  organization  for  a  school  of  nursing  which  should  be  realized  in 
Cleveland  as  soon  as  circumstances  permit  is  clearly  the  University  organiza- 
tion in  which  ward  training  would  be  given  in  such  hospitals  as  come  up  to 
the  conditions  required  by  the  University  for  educational  purposes  for  its 
students. 

12.  The  superintendent  of  nurses  in  the  hospital  should  be  appointed  by 
the  Board  of  Trustees  of  the  hospital,  on  nomination  of  the  superintendent 
of  the  hospital  with  the  concurrence  of  the  training  school  committee.  She 
should  have  administrative  authority,  subject  to  the  superintendent  of  the 
hospital,  over  the  entire  nursing  service  and  she  should  be  responsible  for  the 
educational  standards  and  policies  as  laid  down  by  the  training  school  com- 
mittee. It  is  considered  desirable  that  the  superintendent  of  the  hospital 
should  delegate  to  the  superintendent  of  the  training  school  the  appointment 
and  dismissal  of  nursing  personnel. 

The  offices  of  principal  of  the  training  school  and  superintendent  of  nurses, 
are  educational  and  administrative  offices,  respectively,  and  may  or  may  not 
be  combined  in  the  same  individual.  When  they  are  combined  the  head  of 
the  training  school  should  be  designated  "Superintendent  of  Nurses  and 
Principal  of  the  Training  School." 


848  Hospital  and  Health  Survey 

13.  The  Social  Service  department  of  the  hospital  should  be  under  the 
direction  of  a  head  worker  who  should  be  responsible  to  the  superintendent. 
It  is  recommended  that  there  be  a  Social  Service  Committee,  which  among 
other  members,  should  include  one  or  more  of  the  trustees,  of  the  medical 
staff  and  the  superintendent  of  the  hospital. 


Hospitals  and  Dispensaries  849 


THE  HUMAN  PROBLEM  OF  THE  HOSPITAL  PATIENT 

''Treat  not  only  the  disease,  treat  also  the  man."  These  words  of  Ru- 
dolph Virchow  set  the  standard  for  the  highest  form  of  hospital  service. 
The  two  or  three  thousand  patients  who  are  in  the  hospitals  of  Cleveland 
daily,  present  the  hospitals  not  only  with  a  variety  of  bodily  ills,  but  with 
problems  of  personality  and  environment  which  are  as  varied  as  human 
nature,  and  which  influence  vitally  the  ultimate  success  of  the  hospital's 
mission  to  maintain  as  well  as  to  restore  health. 

Virchow's  words  set  not  only  a  standard  but  express  a  warning,  for  the 
hospital's  great  danger  is  overspecialization — attending  to  pathology  and 
overlooking  personality.  Successful  work  in  the  operating  room  may  be 
independent  of  what  the  patient  is  or  thinks  or  feels,  but  successful  restora- 
tion of  the  patient  to  health  and  living  efficiency  depends  not  only  on  the 
surgery  but  on  the  patient's  state  of  mind  after  he  goes  from  the  operating 
room  to  his  bed  in  the  hospital  and  from  his  bed  in  the  hospital  to  his  home. 

In  a  survey  it  is  necessary  to  consider  persons  as  well  as  patients,  in 
order  that  a  true  picture  be  given  of  the  hospital's  services,  of  their  relation- 
ships to  the  community,  and  of  their  values  and  deficiencies,  as  judged  by 
the  final  results  in  making  people  well  and  humanly  efficient.  The  Survey 
has  therefore  endeavored  to  study  the  people  and  their  reaction  to  the  hos- 
pitals of  Cleveland  as  well  as  the  hospitals  of  Cleveland  in  their  relations  to 
the  people.  Several  hundred  interviews  and  conferences  were  held  with 
physicians,  including  both  members  and  non-members  of  hospital  staffs; 
with  nurses  in  hospitals  and  in  public  health  fields;  with  social  workers; 
with  organizations  of  the  foreign-born;  with  church  workers;  and  with  people 
met  more  or  less  at  random  in  their  homes  or  elsewhere. 

Those  who  are  accustomed  to  hospitals  too  often  fail  to  recognize  how 
new  and  strange  an  experience,  to  the  average  patient,  is  his  first  contact 
with  a  hospital.  The  admission  procedure,  the  unfamiliar  antiseptic  odors, 
the  sight  of  many  sick  people,  the  precise  business-like  efficiency  of  hurry- 
ing nurses  and  doctors,  fill  many  a  patient  with  vague  and  uncertain  ideas 
of  what  may  be  going  on  behind  the  many  closed  doors,  and  what  may 
soon  be  happening  to  himself.  Courage  is  easily  lost  in  the  strange  insti- 
tutional atmosphere.  The  educated  man  who  is  familiar  with  hospitals, 
having  previously  been  a  patient  or  a  visitor,  and  who  is  self-confident  and 
at  ease  even  during  sickness,  is  in  quite  a  different  position  from  the  un- 
informed immigrant  who  has  never  had  contact  with  doctors  or  hospitals 
in  his  life,  or  the  timid  woman,  or  the  sensitive  child. 

It  is  not  that  hospitals  or  their  personnel  lack  kindness  in  the  treatment 
of  the  patients.  It  is  their  business  to  be  helpful,  and  hospitals  and  their 
doctors,  nurses,  and  other  personnel  generally  are,  but  it  is  rather  that  hos- 
pitals are  helpful  in  a  professional  and  technical  way,  while  the  patient  is 
generally  full  of  worrying  questions  he  would  like  to  have  answered,  of  fore- 
bodings which  it  would  be  desirable  to  dispel,  of  states  of  mind  which  depress 
him,  and  which,  if  maintained,  will  hinder  his  recovery.     These  forebodings 


850  Hospital  and  Health  Survey 

and  these  states  of  mind  require  not  merely  a  general  attitude  of  kindness, 
but  sympathetic  insight,  clear  analysis,  and  definite  action  to  dispel. 

The  human  problem  of  the  hospital  patient  can  be  perhaps  best  illustrated 
by  the  foreign-born.  On  the  two  Survey  census  days,  63.1  per  cent,  of  the 
adult  patients  were  American-born,  and  36.9  per  cent,  were  foreign-born. 
According  tq  the  estimates  in  1917,  of  the  Cleveland  Americanization  Com- 
mittee, there  were  744,728  total  population  in  the  city,  of  whom  231,939 
were  of  foreign  birth,  466,142  native  born  of  native  parents  and  281,586 
native  born  of  foreign  or  mixed  parentage.  Those  of  the  third  group  are 
largely  children.  Taking  these  figures,  we  find  that  the  231,939  foreign- 
born  are  49.7  per  cent,  of  the  466,142  native  born  of  native  parentage.  This 
figure  may  be  roughly  compared  with  the  percentage  of  foreign-born  adults  in 
the  hospitals  of  Cleveland,  which  was  just  stated  as  36.9  per  cent.  This  illus- 
trates an  important  point  which  studies  in  other  communities  have  verified 
— that  the  foreign-born  adult  generally  uses  the  hospitals  less  than  the 
American-born  adult.  This  is  largely  because  of  lack  of  familiarity  with  an 
institution  with  which  many  immigrants  had  little  experience,  previous  to 
coming  to  this  country.  It  must  be  remembered  that  a  large  number  of 
recent  immigrants  have  come  from  small  towns  and  many  of  them  think, 
"Hospitals  are  places  where  you  go  to  die."  A  considerable  proportion  of 
the  foreign-born  patients,  moreover,  speak  little  or  no  English. 

The  attitude  of  the  foreign-born  toward  the  hospital  reflects  all  the  lights 
and  shades  of  the  hospital's  own  attitude  toward  its  patients  of  foreign 
birth.  Frequently  the  very  human  and  impressionable  surface  which  the 
foreign-born  presents  ready  for  the  hospital's  sign  and  seal,  is  masked  be- 
hind an -enforced  silence  because  of  unintelligible  speech.  Too  often  the 
phrase  "those  ignorant  foreigners"  shows  merely  lack  of  understanding  by 
the  x\merican-born.  A  common  language  is  the  searchlight  most  useful  in 
discovering  physical,  racial,  or  temperamental  needs,  and  means  of  adjust- 
ing the  hospital  regime  to  treat  these.  When  the  hospital  has  given  time  and 
thought  to  its  task,  it  has  been  able  through  sympathetic  interpretation  to 
convince  the  patient  of  its  friendly  interest,  its  ability  in  diagnosis,  its  skill 
in  treatment,  and  when  this  conviction  is  made  doubly  sure  by  intelligent 
follow-up  work  in  the  home,  there  is  every  evidence  that  the  hospital's  work 
is  worth  while,  that  the  patient  is  grateful  and  appreciative,  and  that  the 
experience  has  been  of  permanent  educational  value  to  him  in  the  matter  of 
personal  and  public  health  and  in  the  growth  of  a  sense  of  social  and  civic 
participation. 

The  result  is  different  when  the  hospital  has  had  no  specific  machinery 
for  getting  at  the  back  of  the  foreign  patient's  mind,  and  making  the  some- 
what inflexible  and  mysterious  hospital  routine  less  a  puzzle  to  him.  The 
patient's  mild  skepticism  as  to  whether  American  hospitals  are  good  places 
for  the  foreign-born,  increases  to  a  large  doubt.  This  is  further  enlarged  by 
his  friends,  who  have  trouble  in  being  understood  at  the  inquiry  desk;  who 
may  be  unable  to  talk  with  the  doctor  or  to  get  the  diagnosis.  If  a  medical 
case,  the  patient  worries  through  a  retarded  convalescence  and  goes  home 
glad  to  be  free — and  wondering!     If  a  surgical  case,  often  his  climax  of 


Hospitals  and  Dispensaries  851 

protest  against  the  vast  unknown  of  Hospital  machinery  is  a  refusal  to  per- 
mit operation.  He  leaves  against  advice,  grateful  for  the  somewhat  peremp- 
tory- discharge  of  the  hospital,  which  in  turn,  feels  inwardly  affronted  that  its 
effort  to  help  should  be  powerless  before  his  unreasoning  "stupidity." 

In  seven  hospitals  the  proportion  of  foreign-born  adult  patients  was  over 
30  per  cent.,  the  maximum  being  as  high  as  47  per  cent.  No  hospital  in 
Cleveland  has  made  any  definite  provision  for  interpreters,  either  as  a 
matter  of  promoting  the  ease  and  comfort  of  the  patient,  or  of  increasing 
hospital  efficiency.  As  a  rule  the  hospital  is  concerned  with  "making  the 
patient  understand" — "We  manage  to  make  them  understand  somehow." 
Some  other  patient  of  the  same  mother  tongue  who  has  learned  English  is 
pressed  into  service,  or  an  employe  or  a  visitor  is  called  upon.  The  prob- 
lem, however,  is  not  merely  "making  the  patient  understand, "  but  is  to  render 
the  patient  "understood. " 

The  following  table,  based  on  the  average  of  the  two  Survey  census  days, 
showed  an  interesting  phase,  the  contrast  between  the  proportion  of  pay, 
part-pay,  and  free  patients  among  the  adult  foreign-born  and  the  American- 
born  patients  in  the  hospitals  of  Cleveland. 


Hospital  Patients  on  Two  Survey  Census  Days,  Averaged 

American-born 
Number        Percentage 

Pay 989  39.2 

Part-pay 735  29.1 

Free 733  29.1 

Information  not  furnished 66  2.6 

Total 2,523  1,474 

The  table  indicates  what  one  would  expect,  that  the  foreign-born  show  a 
much  larger  proportionate  use  of  the  free  beds.  The  generally  higher  eco- 
nomic status  of  the  American-born  is  doubtless  sufficient  explanation. 

One  important  relation  of  the  hospital  to  the  community  is  the  furnishing 
of  information  about  the  condition  of  patients.  Patients  themselves  want  to 
know  how  they  are  getting  on,  and  their  relatives  and  friends  likewise  wish 
this  information.  Hospital  staffs  and  administrators  must  use  their  dis- 
cretion in  what  they  tell  the  patients  or  relatives,  just  as  private  physicians 
do,  yet  the  hospitals  often  fail  to  give  elementary  and  necessary  information 
or  to  give  it  in  a  way  which  will  be  helpful  or  even  useful. 

Many  inquiries  come  by  the  telephone.  A  story  has  been  reported  of  an 
immigrant  family,  very  anxious  to  secure  information  as  to  the  condition  of 
the  father  who  had  been  taken  to  a  hospital  after  an  accident.     Unable  to 


Foreign-born 

Number 

Percentage 

351 

23.8 

444 

30.1 

631 

42.8 

48 

3.3 

852  Hospital  and  Health  Survey 

speak  English,  the  mother  and  her  children  had  recourse  to  the  neighbor- 
hood druggist.  He  called  up  the  hospital  ihree  times,  and  was  unable  to 
learn  anything  that  would  either  satisfy  himself  or  relieve  the  "family's 
acute  anxiety.  The  error  was  not  inhumanity  on  the  part  of  the  hospital, 
for  the  information  was  later  furnished  readily,  but  was  due  to  the  fact  that 
the  telephone  operator  had  not  been  taught  to  appreciate  the  importance  of 
interpreting  the  hospital  to  the  public.  This  incident  would  not  be  men- 
tioned were  it  not  an  illustration  of  many. 

i 
The  importance  of  this  duty  is  often  not  sufficiently  clear  to  the  hospital 
administration  to  make  them  provide  adequate  instruction  to  the  person  or 
persons  who  are  responsible  for  answering  such  inquiries,  either  in  person  or 
over  the  telephone,  or  to  cause  the  selection  of  a  sufficiently  trained  and 
tactful  person  to  perform  this  function. 

Sometimes  a  mother  is  eager  to  see  her  child  frequently.  There  are 
often  perfectly  good  reasons  why  she  should  not  see  the  child  at  all  or  during 
certain  periods,  but  not  infrequently  there  is  failure  to  explain  to  an  anxious 
family  why  the  privilege  is  denied. 

Interpretation  of  the  hospital's  work,  rules  and  results  to  the  public  is 
part  of  the  hospital's  job.  The  public  includes  its  own  patients,  their  rela- 
tives and  friends,  and  also  the  broader  circle  of  the  hospital's  supporters, 
and  any  one  in  the  community,  in  fact,  who  has  a  reason  to  be  interested  in 
the  hospital's  activities.  This  interpretation  of  the  hospital's  work,  rules 
and  results,  is  made  partly  in  the  hospital's  formal  reports  and  partly  through 
its  daily  relations  with  its  patients  and  those  interested  in  them.  Too  little 
attention  has  been  given  to  such  interpretation  through  the  channels  of  the 
hospital's  routine  contacts. 

The  patient's  lack  of  understanding  of  the  hospital  is  too  often  matched 
by  the  hospital's  lack  of  understanding  of  the  patient.  The  patient  can  be 
greatly  helped  to  understand  the  hospital  by  the  right  procedure  at  the  time 
of  admission.  Hospitals  which  maintain  dispensaries  should  use  the  dis- 
pensary as  the  means  through  which  patients  are  admitted  to  the  wards. 
The  provision  of  a  trained  and  tactful  member  of  the  social  service  depart- 
ment in  connection  with  the  admission  desk  of  the  dispensary  will  serve  to 
start  many  patients,  who  will  later  be  referred  from  the  dispensary  to  the 
wards,  with  some  understanding  about  hospitals  in  general  and  this  hospital 
in  particular.  From  this  standpoint,  the  two  critical  points  in  the  patient's 
hospital  career  are  the  day  of  admission  and  the  time  of  or  just  before  dis- 
charge. 

A  considerable  portion  of  patients  are  sent  to  the  hospitals  by  charitable 
societies.  On  the  Survey  census  days,  it  appeared  that  an  average  total  of 
201  patients,  or  11.8  per  cent,  of  all  patients,  had  been  admitted  to 
hospitals  at  the  request  of  some  charitable  agency.  In  the  case  of  these 
patients,  the  charitable  society  stands  to  the  hospital  as  an  interested  party. 
If  its  work  with  the  patient  and  with  the  family  is  to  be  successful,  it  may 
need  to  know  the  physical  condition  of  the  patient,  and  the  prognosis.     It 


Hospitals  and  Dispensaries  853 

is  the  duty  of  the  hospital  to  cooperate  with  the  charitable  society  by  fur- 
nishing the  necessary  information,  consistent  with  the  interests  of  the  in- 
dividual patient. 

The  hospitals  have  not  always  met  this  responsibility  completely  or  wisely, 
because  of  the  same  deficiency  just  mentioned,  lack  of  a  definite  sense  of 
responsibility  for  interpreting  the  hospital's  work,  and  failure  to  assign  a 
sufficiently  trained  and  responsible  person  to  the  task. 

A  considerable  portion  of  the  patients  in  some  institutions  come  as  in- 
dustrial accident  cases,  or  are  sent  through  a  medical  department  conducted 
at  some  commercial  or  manufacturing  establishment.  The  special  report 
of  the  Survey  on  industrial  medicine  and  hygiene  (Part  VII),  deals  with 
this  matter,  but  in  an  industrial  community  like  Cleveland  its  importance 
justifies  mention  here.  The  hospitals  need  to  serve  industry,  and  industry 
should  support  the  hospitals  adequately  in  return  for  service. 

What  can  the  hospital  do  in  relation  to  the  difficult  problem  of  the  foreign- 
born  who  do  not  speak  English?  The  calling  in  of  paid  interpreters  is  finan- 
cially impossible  in  most  of  the  smaller  hospitals.  Moreover,  no  one  inter- 
preter can  speak  every  language  and  almost  any  language  of  western  Europe 
is  likely  to  be  called  for  sometime.  Few  if  any  hospitals  could  afford  even 
one  full-time  interpreter,  or  could  manage  to  keep  such  a  functionary  busy 
with  the  particular  patients  whose  language  he  could  speak.  The  problem 
of  hospital  interpretation  cannot  be  solved  by  paid  interpreters  employed  by 
the  individual  hospitals.  The  chief  practical  recommendations  to  be  made 
are  these: 

If  a  hospital  and  its  out-patient  department  are  taken  together,  a  sufficient 
number  of  patients  speaking  a  given  foreign  language  or  group  of  related 
languages  might  come  to  the  institution  on  an  average  day  to  justify  and 
require  the  entire  time  of  an  interpreter,  and  the  work  in  the  two  branches 
could  be  adjusted  so  as  not  ordinarily  to  conflict.  The  use  of  full-time  in- 
terpreters, however,  doing  no  other  work,  must  necessarily  be  limited  to 
very  large  institutions,  such  as  the  new  City  Hospital  will  be.  Most  hos- 
pitals which  receive  patients  not  speaking  English  should  solve  the  problem 
of  interpretation  by  depending  on  specially  trained  nurses  or  social  workers 
or  by  calling  in  the  aid  of  outside  organizations  interested  in  the  foreign- 
born  or  of  the  foreign-born  themselves.  Hospital  superintendents  in  engaging 
employes  for  certain  positions  should  consider  ability  to  speak  certain  for- 
eign languages  as  an  asset  and  a  reason  for  the  engaging  of  a  particular 
individual.  Really  good  interpretation  in  securing  medical  and  social  his- 
tories and  in  meeting  the  patient's  human  needs  while  in  the  hospital,  cannot 
be  obtained  by  calling  in  an  uneducated  orderly.  The  main  reliance  should 
be  upon  nurses  and  members  of  the  social  service  department  who  have  a 
definite  professional  sense  of  responsibility  for  the  hospital  patients. 

In  communities  having  a  considerable  number  of  foreign-born  of  any  one 
race  group,  cooperation  can  usually  be  obtained  from  immigrant  organiza- 
tions themselves.     These  organizations  should  be  encouraged  to  serve  as 


854  Hospital  and  Health  Survey 

visitors  to  patients  of  their  own  race  who  have  not  other  friends  and  in  help- 
ing with  the  more  difficult  and  special  cases  in  which  interpretation  is  neces- 
sary and  beyond  the  power  of  any  employe  of  the  hospital.  Enough  hos- 
pitals are  now  utilizing  outside  cooperation  of  this  sort  sufficiently  to  show 
that  it  is  gladly  provided  by  immigrant  organizations  (or  by  American 
immigrant  welfare  societies  where  they  exist)  without  cost  to  the  hospital 
and  to  the  mutual  benefit  of  both  sides.  Such  an  arrangement  with  immi- 
grant organizations  would  go  a  long  way  toward  promoting  general  under- 
standing of  the  hospital  by  the  people  of  that  group  in  the  community. 

These  plans,  however,  cannot  be  effective  unless  some  department  of  the 
hospital  and  ultimately  some  individual  is  definitely  charged  with  organizing 
and  keeping  up  the  system  of  interpretation.  Generally  speaking,  the  social 
service  department  should  be  charged  with  this  responsibility  and  some  member 
of  the  staff  of  the  department  should  be  selected  to  carry  out  the  responsibility 
who  is  especially  qualified  and  interested.  A  hospital  which  has  any  con- 
siderable proportion  of  foreign-born  patients  should  make  a  point  of  having 
in  its  social  service  department  someone  who  is  able  to  speak  at  least  one  of 
the  foreign  languages  common  among  patients  and  who  has  secured  special 
knowledge  and  training  in  the  backgrounds  and  characteristics  of  several 
immigrant  groups  so  that  she  is  capable  of  fulfilling  these  duties.  This  will 
involve  some  inside  work  with  various  hospital  employes,  particularly  nurses 
and  other  members  of  the  social  service  department;  the  use  of  phrase  books; 
the  encouragement  of  various  means  by  which  nurses  and  social  workers 
may  secure  knowledge  about  the  backgrounds  and  characteristics  of  the 
chief  immigrant  groups.  An  effort  should  be  made  to  interest  internes  in 
the  same,  and  this  should  have  the  support  not  only  of  the  hospital  superin- 
tendent but  of  the  chiefs  of  the  medical  staff.  It  should  be  made  apparent 
that  thus  better  histories  can  be  obtained,  better  cooperation  of  the  patient 
secured,  and  better  medical  results  achieved. 

The  critical  moment  for  the  patient,  from  the  standpoint  of  disease,  is 
often  the  time  of  admission  to  the  hospital,  but  the  critical  time  for  the 
patient  from  his  standpoint  as  a  person  is  usually  at  or  a  little  before  dis- 
charge. In  the  discussion  of  the  problem  of  convalescent  care  (page  000)  will 
be  found  statistics  indicating  that  a  large  majority  of  hospital  patients 
leave  the  hospital  needing  some  definite  form  of  medical  care,  either  in  their 
homes,  in  a  dispensary,  or  in  an  institution  for  convalescents.  The 
information  gathered  in  Cleveland  agrees  entirely  with  the  studies  and 
estimates  of  Dr.  Frederic  Brush,  the  leading  national  authority  on  con- 
valescent care,  that  the  medical  job  is  not  done  at  the  time  the  patient 
leaves  the  hospital.  The  hospital's  responsibility  as  a  hospital  is  not  always 
to  do  this  medical  job,  but  it  must  link  the  patient  with  the  physician,  the 
dispensary,  the  convalescent  home,  or  other  organization  which  will  perform 
the  needed  service. 

The  beginning  of  this  connection  is  the  explanation  to  the  patient  (or 
to  his  parents,  if  the  patient  is  a  child)  of  the  patient's  condition,  in  terms 
that  will  be  understood  by  the  lay  mind;  of  what  need  exists,  if  any,  for 
further  medical   supervision;    or   of  what  daily  routine   of  diet,   hygiene, 


Hospitals  and  Dispensaries  855 

exercise,  and  occupation  is  desirable  during  the  period  after  discharge. 
Explanation  to  the  patient  or  to  those  responsible  for  the  patient,  of  the 
patient's  condition  on  discharge  and  what  may  be  called  the  needed  pro- 
gram for  after-care,  is  a  definite  responsibility  which  few  hospitals  in  Cleve- 
land have  met,  save  in  exceptional  instances.  It  is  part  of  the  hospital's 
responsibility  to  have  a  definite  system  for  meeting  this  need. 

At  a  few  hospitals  there  has  been  established  a  so-called  follow-up  sys- 
tem, usually  modeled  upon  that  of  the  American  College  of  Surgeons.  This 
aims  to  secure  for  the  medical  staff  the  results  of  operations  or  the  condition 
of  the  patient  at  a  certain  period  after  discharge,  such  as  three  months, 
six  months,  or  a  year.  Such  information  is  of  medical  value  to  the  staff, 
and  in  the  long  run  will  tend  to  the  advancement  of  medical  science  and  the 
improvement  of  service  to  patients.  But  the  term  "fish-up"  instead  of 
"follow-up"  should  be  applied  to  a  method  which  merely  secures  facts  as 
to  a  patient's  condition  a  certain  time  after  he  is  discharged,  and  does  not 
in  some  definite  and  effective  way  help  to  make  the  conditions  during  this 
period  what  they  should  be.  A  follow-up  and  not  a  fish-up  system  is  the 
standard  which  should  be  set  in  a  progressive  community  like  Cleveland, 
which  wishes  to  obtain  100  per  cent,  value  from  the  medical  work  of  the 
institutions  which  it  supports. 

When  it  is  found  that  six  per  cent,  of  £00  patients  recently  discharged 
from  four  of  the  leading  hospitals  needed  continued  hospital  care — in  other 
words,  had  relapsed  since  their  discharge;  when  it  is  found  that  12.5  per 
cent.,  in  addition,  were  living  under  such  home  conditions  that  satisfactory 
convalescence  was  unlikely  (See  Table  VII.,  Appendix),  it  is  apparent  that 
expensive  hospital  service  is  easily  wasted  because  of  the  lack  of  a  little  fur- 
ther service  which  would  have  made  all  the  preceding  work  permanently 
worth  while. 

"Should  the  social  service  department  have  the  responsibility  for  the 
problem  of  after-care?"  Xo!  The  medical  staff  of  a  hospital  have  the 
responsibility  for  the  care  of  its  patients,  and  making  a  medical  program 
for  after-care  is  a  part  of  that  responsibility  which  cannot  rightly  or  effec- 
tively be  delegated.  When  it  comes  to  carrying  out  the  details  of  the  work, 
the  social  service  department  has  a  definite  place,  as  will  be  brought  out 
more  fully  later  in  discussing  this  subject.  The  social  service  department 
can  assist  the  staff  of  the  hospital  in  securing  the  facts  regarding  the  pa- 
tient's personality,  family  housing,  home  conditions,  neighborhood,  and 
finances,  which  in  conjunction  with  the  medical  facts  known  regarding  the 
patient's  condition,  will  enable  the  responsible  member  of  the  staff  to  for- 
mulate a  program  for  after-care.  When  it  comes  to  assisting  in  carrying 
out  the  program,  the  social  service  department  generally  has  been  and 
usually  should  be  called  in,  either  to  make  explanations  to  the  patient  or 
to  arrange  for  contact  with  the  Visiting  Xurse  Association,  the  Department 
of  Health  nurses  or  a  charitable  society  which  will  be  able  to  exercise  super- 
vision, to  assist  in  improving  home  conditions  or  in  securing  the  institu- 
tional care  that  may  be  required. 

As  the  facts  in  the  section  on  convalescence  bring  out,  the  need  for  finan- 
cial aid  during  after-care  is   approximately  much  less  frequent  than   the 


856  Hospital  and  Health  Survey 

need  for  explanation  and  advice.,  given  in  terms  of  the  patient's  degree  of 
education  and  understanding,  and  of  the  practical  conditions  of  his  environ- 
ment. 

The  dispensary  attached  to  the  hospital  should  be  used  as  one  of  the  means 
of  providing  after-care  of  discharged  patients.  Reference  of  the  patient 
to  the  dispensary  should  be  made  in  every  instance  where  further  super- 
vision is  necessary  and  the  patient  cannot  pay  a  private  physician.  The 
follow-up  system  should  insure  the  actual  return  of  the  patient  to  the  dis- 
pensary in  a  large  majority  of  instances. 

In  summary,  the  patient's  lack  of  understanding  of  the  hospital  needs 
to  be  overcome  by  development  of  the  admission  procedure,  which  should 
be  concerned  with  more  than  the  elementary  procedure  of  registration, 
assignment  to  a  definite  ward  or  room,  and  fixation  or  remission  of  fees,  and 
which  should  include  educational  and  interpretative  elements.  The  special 
problem  of  the  non-English  speaking  foreigner  should  be  met  at  the  time 
of  admission,  and  later  through  some  definite  provision  for  interpretation, 
both  by  hospital  personnel  and  through  the  cooperation  of  associations 
interested  in  immigrants,  as  above  suggested. 

The  utilization  of  the  dispensary  as  the  place  of  admission  for  ward 
patients  will,  if  the  dispensary  admission  system  is  rightly  organized  and 
its  personnel  rightly  selected,  enable  the  average  ward  patient  to  go  into 
a  hospital  bed  with  some  previous  understanding  of  the  situation. 

The  hospital  has  a  definite  responsibility  for  interpreting  the  patient's 

condition  to  him  or  to  those  responsible  for  him,  in  terms  which  can  be 
understood  by  laymen  and  which  will  be  a  practical  help;  also  of  explaining 
and  of  helping  at  least  in  the  beginning  in  the  needed  program  for  medical 
after-care.  This  is  part  of  the  medical  responsibility  of  the  hospital,  and 
while  a  social  service  department  is  of  great  assistance  both  in  securing 
facts  regarding  the  patient's  personality  and  environment,  and  in  helping 
to  carry  out  the  medical  after-care  or  referring  the  patient  to  an  agency 
which  will  do  so,  a  hospital  which  has  no  social  service  department  should 
still  be  responsible  and  be  able  actually  to  provide  for  at  least  the  explana- 
tion to  the  patient  or  his  relatives,  and  the  definite  reference  of  the  patient 
to  the  needed  sources  of  after-care. 

The  medical  staff  of  the  hospital,  through  its  executive  committee, 
should  be  expected  to  define  the  duty  of  the  hospital  in  this  respect,  so  the 
administrators  of  the  hospital  can  have  medical  authority  behind  them  for 
seeing  that  this  responsibility  is  carried  out  by  visiting  and  resident  staff, 
nursing  and  administrative  assistants,  and  by  the  social  service  department 
if  there  is  one. 

Answering  inquiries  regarding  patients  is  a  definite  part  of  the  hos- 
pital's duty  to  the  community  and  should  be  fulfilled  according  to  a  defi- 
nite cooperative  policy  by  carefully  instructed  members  of  the  hospital's 
administrative  personnel.  Cooperation  with  charitable  agencies  in  behalf  of 
their  patients  is  a  particularly  significant  responsibility  of  the  hospital, 
affecting  no  inconsiderable  proportion  of  the  ward  patients. 


Hospitals  and  Dispensaries  857 

In  the  long  run,  the  degree  of  support  of  the  hospitals  of  Cleveland  will 
depend  upon  the  degree  to  which  their  work  is  appreciated  by  the  com- 
munity. The  elaborate  facilities,  equipment,  staff,  and  organization  needed 
for  the  thorough  study  and  treatment  of  hospital  cases  require  an  increas- 
ingly high  degree  of  appreciation  on  the  part  of  the  community  of  just  what 
hospital  work  is,  what  it  requires,  and  what  it  costs.  The  foundation  of 
appreciation  is  understanding.  Anyone  grasps  the  beneficent  service  of  a 
hospital  to  the  emergency  accident  patient,  but  understanding  of  the  less 
obvious  and  more  typical  cases,  which  constitute  the  large  majority  of  pa- 
tients, is  not  so  easy.  The  patient's  lack  of  understanding  of  the  hospital  is 
pardonable  at  the  time  of  entrance.  The  patient's  lack  of  understanding  of 
the  hospital  at  the  time  of  discharge  is  a  misfortune  to  the  patient  and  to  the 
hospital  as  well.  Only  on  the  basis  of  mutual  understanding  can  adequate 
support  for  the  best  hospital  work  be  built  up  and  maintained  in  Cleveland. 


858  Hospital  and  Health  Survey 

THE  MEDICAL  PROFESSION  AND  THE  HOSPITALS 

In  the  City  of  Cleveland  the  American  Medical  Directory  of  1918  gives  a 
list  of  1,169  physicians,  of  whom  1,050  are  stated  to  be  in  active  practice. 
A  tabulation  of  the  staff  lists  of  the  members  of  the  Hospital  Council  showed 
that  309,  or  29  per  cent,  of  the  total  were  on  the  staff  of  a  hospital  or  dispen- 
sary, while  71  per  cent,  had  no  such  connection.  Allowing  for  the  small 
number  of  additional  physicians  on  the  staffs  of  the  non-council  hospitals,  it 
is  certainly  true  that  two-thirds  of  the  medical  profession  appear  to  have  no 
connection  with  organized  medical  service. 

A  similar  comparison  made  about  five  years  ago  in  Boston  indicated  that 
the  proportion  of  physicians  having  a  hospital  or  dispensary  connection  was 
about  50  per  cent,  larger.  In  New  York,  figures  collected  by  the  Public- 
Health  Committee  of  the  Academy  of  Medicine  indicated  that  almost 
exactly  50  per  cent,  of  the  medical  profession  in  New  York  were  on  hospital 
or  dispensary  staffs.  Cleveland  thus  has  relatively  more  physicians  than 
either  of  these  two  cities  who  are  not  members  of  any  hospital  or  dispensary 
organization. 

It  is  apparent  that  so  far  as  membership  on  a  hospital  staff  implies  ad- 
vantages for  the  scientific  study  of  disease,  for  the  use  of  special  equipment, 
and  for  consultation  with  specialists,  the  majority  of  physicians  of  Cleve- 
land have  not  these  advantages.  So  far  as  membership  on  hospital  staff 
gives  control  in  the  use  of  hospital  facilities,  tabulation  of  the  Cleveland 
hospitals  by  number  of  beds  and  size  of  staff  shows  that  about  25  per  cent,  of 
the  medical  profession  have  control  of  about  80  per  cent,  of  the  hospital 
beds. 

A  patient  may  of  course  be  admitted  to  a  hospital  at  which  his  private 
physician  is  not  a  member  of  the  staff,  but  if  the  patient  is  a  ward  case,  the 
physician  then  loses  the  right  to  treat  him.  General  complaint  was  made  to 
the  Survey  during  the  first  months  of  its  work  by  physicians  who  were  not 
on  hospital  staffs,  that  they  often  could  not  secure  admission  of  their  pa- 
tients to  hospitals  even  as  private  cases,  and  of  course  they  also  complained 
of  the  many  instances  in  which  the  patients  were  admitted  to  wards,  when 
the  care  of  the  patients  had  to  be  resigned  to  the  members  of  the  regular 
hospital  staff. 

A  study  of  the  sources  from  which  patients  were  admitted  to  hospitals 
on  the  two  Survey  census  days  showed  the  following: 

Request  for  Admission  Percentage 

By  staff  physician 51 .3% 

By  non-staff  physician 33 .2% 

By  charitable  or  relief  agency - 11 .8% 

Source  not  stated 3.7% 

Note — In  this  tabulation  City  Hospital,  Warrensville  Tuberculosis 
Sanatorium,  and  Rainbow  Hospital  are  omitted,  as  admissions  at  these  in- 
stitutions are  on  a  different   basis   from   those   at  general  hospitals. 


Hospitals  and  Dispensaries  859 

These  figures  appear  to  indicate  that  a  considerable  number  of  physicians 
not  members  of  the  hospital  staffs  may  and  do  send  their  patients  to  the  hos- 
pitals and  treat  them  as  private  cases.  It  is  quite  evident,  however,  that  a 
large  number  of  the  1,050  practising  physicians  in  Cleveland  have  little  if 
any  contact  with  the  hospitals  even  in  this  way. 

There  are  wide  variations  shown  in  the  proportion  of  patients  admitted 
through  non-staff  physicians.  The  variation  depends  less  on  the  size  of  the 
hospital  than  on  the  number  and  organization  of  its  regular  attending  staff. 
Thus  some  of  the  small  hospitals  have  relatively  large  staffs,  and  physicians 
not  members  thereof  apparently  rarely  secure  admission  for  their  patients. 
On  the  other  hand,  some  hospitals  of  similar  size  showed  on  the  census  days 
a  high  percentage  of  patients  admitted  by  non-staff  physicians — proportions 
ranging  up  to  83  per  cent.    - 

Figures  for  a  group  of  large  general  hospitals  may  be  of  interest,  as  show- 
ing the  wide  variation  found.     These  are  shown  in  Table  V.  in  the  Appendix. 

Part-pay  and  free  cases  may  be  admitted  through  non-staff  physicians, 
but  are  rarely  treated  by  other  than  members  of  the  regular  staff.  In  the 
group  of  pay  patients,  on  the  other  hand,  there  are  a  considerable  number  of 
private  patients  among  the  cases  which  are  admitted  through  non-staff 
physicians  and  who  then  usually  remain  under  their  care. 

It  must  be  recalled  that  these  percentages  relate  only  to  the  two  census 
days,  but  there  is  reason  to  believe  that  the  figures  are  representative  of  the 
usual  relationships  between  the  patients  admitted  through  members  of  the 
staff  and  those  admitted  through  non-staff  physicians. 

The  general  attitude  of  a  hospital  toward  the  non-members  of  the  staff 
is  expressed  by  its  admission  policy.  Most  hospitals  receive  private  patients 
and  most  hospitals  have  a  rule  that  such  patients  are  accepted,  when  va- 
cancies exist,  from  any  reputable  physician.  In  practice,  however,  it  is  rea- 
sonable and  inevitable  that  the  members  of  the  officially  appointed  attending 
staff  have  the  closest  contact  with  the  hospital  and  are  likely  to  fill  a  consider- 
able proportion  of  its  beds.  When  such  shortage  of  beds  exists  as  in  Cleve- 
land, the  difficulty  felt  by  many  physicians  not  on  hospital  staffs  in  secur- 
ing admission  of  their  private  patients  is  not  more  than  may  be  expected. 
There  has  been  no  substantial  evidence  that  the  administration  of  the  hos- 
pitals, year  in  and  year  out,  has  been  unduly  inconsiderate  of  the  private 
physician  of  good  standing  who  sought  admission  for  his  patient.  Mem- 
bers of  the  official  staff  have  received  reasonable  preference  but  this  is  only 
natural.  Until  more  beds  are  available  for  private  patients  of  physicians 
in  privately-supported  hospitals,  present  conditions  cannot  be  expected  to  be 
radically  improved. 

In  a  few  institutions  there  has  been  found  a  practice,  not  formally  recog- 
nized by  rule,  but  real  nevertheless — of  holding  beds  vacant  twenty-four 
hours  or  even  more  because  certain  members  of  the  staff  were  likely  to  wish 


860  Hospital  and  Health  Survey 

to  send  patients  in.     A  practice  of  this  kind  is  unjustifiable,  but  is  excep- 
tional in  Cleveland. 

A  study  of  the  degree  to  which  members  of  hospital  staffs  overlap  revealed 
the  fact  that,  except  in  the  teaching  institutions  affiliated  with  Western 
Reserve  University  Medical  School,  there  is  no  large  degree  of  multiple 
membership  on  hospital  staffs.  Even  in  the  case  of  University  teaching 
at  Lakeside,  City,  and  St.  Vincent's  Hospitals,  there  is  little  actual  overlap- 
ping of  the  staffs.  The  number  of  men  holding  positions  in  the  staffs  in  one 
or  more  hospitals  in  Cleveland  is  shown  in  the  following  table: 

Multiple  Membership  on  Hospital  Staffs 

233  physicians,  or    22.2%  of  total  number,  serve  on   1  hospital  staff 

55           "  "      5.2%    "  "             "           "       "    2        "        staffs 

15           "  "      1.4%    "  "             "           "       "    3        " 

5           "  "0.5%    "  "             "           "       "    4        "             " 

These  memberships,  however,  include  some  inactive  as  well  as  active 
memberships.  In  general,  active  membership  in  more  than  one  hospital 
staff  is  not  wise,  except  in  the  case  of  multiple  membership  held  for  teaching 
purposes  or  in  the  case  of  men  who  are  engaged  in  restricted  specialties  of 
medicine  or  surgery  and  can  render  these  special  services  to  a  number  of 
institutions  with  benefit  to  all.  Of  the  42  members  of  the  City  Hospital 
staff,  26  are  nominally  active  members  of  other  hospital  staffs.  This,  how- 
ever, is  a  teaching  institution.  The  instances  in  which  a  physician  is  carry- 
ing several  active  memberships  in  hospital  staffs  in  Cleveland  are  propor- 
tionately small.  Some  of  these  individual  instances,  however,  are  worthy 
of  notice,  and  the  Survey,  in  its  reports  to  the  several  boards  of  trustees, 
has  called  them  to  the  attention  of  the  individual  hospitals  concerned.  A 
position  involving  active  service  in  one  hospital  ought  to  be  sufficient  for  a 
physician  and  it  is  wiser  for  his  attention  to  be  concentrated  on  this  institu- 
tion than  to  be  divided  among  several.  Multiple  membership,  therefore, 
with  the  exceptions  noted,  should  be  discouraged. 

In  connection  with  Western  Reserve  Medical  School,  the  following 
figures  are  of  interest.  331  of  the  1,169  listed  physicians  in  Cleveland  are 
graduates  of  Western  Reserve  University  Medical  School — 28.3  per  cent,  of 
the  total.  Of  the  309  staff  positions  in  the  hospitals  and  dispensaries  of  Cleve- 
land, 75,  or  24.2  per  cent,  are  held  by  graduates  of  Western  Reserve  Uni- 
versity Medical  School.  It  will  be  seen  that  the  proportionate  number  of 
positions  held  by  graduates  of  this  medical  school  is  somewhat  smaller  than 
the  number  of  graduates  of  the  school  among  the  medical  profession  as  a 
whole.  It  should  be  added  that  in  the  hospital  and  dispensary  positions 
31  in  addition  to  the  75  just  named,  are  held  by  members  of  the  medical 
school  faculty  who  are  themselves  graduates  of  other  schools.  This  gives  a 
total  of  only  106  out  of  the  309  hospital  and  dispensary  staff  positions  which 
are  held  by  graduates  or  members  of  the  faculty  of  Western  Reserve  Medical 
School. 


Hospitals  and  Dispensaries  861 

In  connection  with  the  so-called  "democratizing"  of  hospital  facilities 
for  the  medical  profession,  it  should  be  pointed  out  that  no  hospital  can  be 
satisfactorily  managed  without  a  definite  official  staff.  A  medical  boarding 
house,  as  previously  defined,  is  merely  a  nursing  home  in  which  physicians 
treat  private  patients.  Any  hospital  which  endeavors  to  maintain  a  medical 
organization,  equipment,  and  personnel,  for  diagnosis  and  treatment,  must 
have  some  medical  authority  appointed,  to  be  responsible  to  its  managing 
body.  A  number  of  the  proprietary  hospitals  are  maintained  by  one  or  more 
physicians  who  conduct  them  as  their  own  enterprises,  and  who  are  medically 
as  well  as  financially  responsible.  The  public  service  hospital  with  a  board 
of  trustees  or  other  disinterested  governing  body,  must  appoint  an  official 
attending  staff.  The  functions  of  this  staff  are  not  only  the  care  of  patients, 
excluding  such  patients  as  are  admitted  specifically  as  private  patients  of 
non-staff  physicians.  Its  functions  also  include  the  determination  and  main- 
tenance of  the  standards  of  medical  practice  which  shall  be  observed  in  the 
institution.  A  medical  staff  of  a  hospital  should  not  be  merely  a  group  of 
individuals  each  of  whom  has  a  certain  ward  or  number  of  beds  under  his 
charge,  for  a  year  or  part  of  a  year,  but  it  is  or  should  be  an  organization — 
a  group  of  physicians  representing  different  branches  of  medicine  and  sur- 
gery, organized  for  the  joint  practice  of  medicine  with  the  equipment  and 
facilities  provided  by  the  hospital,  defining  and  maintaining  the  profes- 
sional standards  and  policies  which  shall  be  effective  throughout  the  insti- 
tution. 

In  some  hospitals  the  medical  staff  does  not  fulfill  these  functions  ade- 
quately. It  does  not  set  clearly  defined  standards  which  govern  the  practice 
of  physicians  in  the  institution.  Thus  in  the  matter  of  record  keeping, 
there  are  a  number  of  hospitals  in  which  fairly  accurate  and  complete  records 
are  kept  upon  ward  patients,  showing  that  physical  examination  was  made, 
laboratory  tests  performed,  and  that  careful  notes  were  entered  at  the  time  of 
operation  or  during  the  course  of  the  patient's  treatment.  In  the  same 
institution,  the  records  of  the  private  patients  of  physicians  may  be  limited 
to  identifying  or  financial  data,  and  have  almost  no  medical  information  of 
significance.  Such  a  hospital  has  not  maintained  (so  far  as  the  records  show) 
the  same  standard  of  care  for  private  patients  as  for  part-pay  or  free  pa- 
tients, who  come  under  the  charge  of  the  hospital's  attending  staff  without 
remuneration.  Records  are  not  always  a  complete  index  of  the  degree  of 
care  actually  provided,  yet  there  can  be  no  doubt  that  particularly  in  the 
matter  of  laboratory  tests  and  consultation  with  specialists,  part-pay  and 
free  cases  in  many  hospitals  receive  more  thorough  study  than  do  many 
private  patients.  Greater  privacy  and  more  intimate  personal  relation  of 
the  patient  to  the  family  physician  are  maintained  for  the  private  case  as  a 
possible  counter-balance. 

In  proportion  as  the  general  public  and  trustees  of  hospitals  appreciate 
that  a  modern  hospital  should  not  be  a  medical  boarding  house  in  whole  or 
in  part,  but  a  medical  organization  in  which  the  best  resources  which  the 
hospital  has  to  offer  in  equipment  or  personnel  should  be  made  available  for 
every  patient  in  so  far  as  he  needs  them,  hospital  organizations  and  hospital 
procedures  will  be  uniform  for  all  classes  of  patients,  private,  part-pay,  and 
free.     Patients  and  physicians  alike  will  profit  by  such  a  policy. 


862  •  Hospital  and  Health  Survey 

With  these  principles  in  mind,  there  have  been  appended  to  this  chapter 
certain  details  which  supplement  the  general  principles  of  hospital  organ- 
ization stated  in  the  section  on  Organization  for  Service. 

The  organization  of  the  medical  executive  committee  is  for  the  purposes 

(a)  of  providing  the  medical  staff  with  a  small  group  which  will  enable  it  to 
conduct  the  routine  business  of  its  organization,  formulate  hospital  standards 
and  policies,' and  make  arrangements  for  the  monthly  staff  meetings;  and 

(b)  of  providing*  a  group  for  regular  conferences  with  the  superintendent  of  the 
hospital,  and,  from  time  to  time,  conferences  with  representatives  of  the 
board  of  trustees,  to  assist  in  administering  the  hospital  satisfactorily. 

The  provision  of  an  auxiliary  staff  is  believed  important,  particularly  in 
view  of  conditions  such  as  those  of  Cleveland.  It  is  highly  desirable  that 
the  number  of  physicians  having  some  connection  with  hospital  staffs  should 
be  increased.  On  the  other  hand,  it  is  essential  that  active  attending  staffs 
of  every  hospital  be  not  so  large,  in  proportion  to  the  number  of  beds,  is  to 
be  unwieldy  or  incoherent.  Otherwise  standards  of  service  are  likely  to  suffer. 
The  organization  of  an  auxiliary  staff  provides  a  means  of  recognizing  in  a 
definite  way  physicians  who  are  utilizing  the  institution  for  their  private 
patients  or  for  consultation  purposes,  and  for  giving  such  physicians  a  definite 
channel  through  their  delegates  whereby  they  can  express  themselves  to  the 
official  staff  or  to  the  hospital  trustees. 

Beyond  such  machinery  of  organization,  other  means  exist  for  opening 
the  facilities  of  Cleveland  hospitals  and  dispensaries  to  a  larger  proportion 
of  the  medical  profession.  It  is  not  only  in  connection  with  the  surgical 
operation  upon  a  patient,  but  also  in  the  medical  treatment  of  acute  cases, 
that  physicians  need  the  advantages  of  the  diagnostic  equipment  of  hospitals 
and  dispensaries,  and  of  the  skill  of  specialists  on  their  staffs.  The  labora- 
tory, the  X-Ray  department  and  other  diagnostic  equipment,  and  the  service 
of  specialists  need  to  be  utilized  by  the  private  physician  in  behalf  of  his 
patient.  To  make  the  splendid  equipment  and  personnel  of  Cleveland  hos- 
pitals available  for  diagnostic  purposes  to  the  medical  profession  of  Cleve- 
land on  a  large  scale  is  one  of  the  chief  goals  to  be  sought  for.  This  must  be 
worked  out  in  practice  largely  through  the  increase  of  dispensary  service  in 
the  form  of  diagnostic  clinics,  to  be  available  for  consultation  purposes  for 
non-staff  physicians.  More  detailed  reference  to  this  is  made  in  the  succeed- 
ing chapters  on  dispensaries. 

The  enlargement  of  dispensary  service  which  Cleveland  so  greatly  needs 
would  provide  opportunity  for  a  considerable  number  of  physicians  to  come 
into  close  contact  with  hospital  work,  as  dispensary  staffs  should  be  organ- 
ized in  intimate  relation  with  hospital  staffs.  (See  page  846.)  The 
medical  advantages  of  facilities  for  diagnosis,  of  consultation,  and  in  general, 
of  intimate  contact  and  co-working  with  other  progressive  physicians  could 
be  opened  to  a  very  large  number  of  physicians  not  now  on  the  staffs  of 
Cleveland  medical  institutions.  The  approximate  proportion  of  physicians 
connected  with  hospitals  and  dispensaries  in  Cleveland  ought  surely  not  to 
be  less  than  in  New  York  (about  50  per  cent.)  which  would  mean  the  addi- 
tion of  200  or  250  physicians  to  the  staffs.     If  dispensary  service  in  Cleveland 


Hospitals  and  Dispensaries  863 

is  developed  as  it  should  be  during  the  next  few  years,  this  result  may  be 
measurably  achieved. 

There  are  certain  groups  in  the  medical  profession  who  feel  that  their 
opportunities  in  the  medical  institutions  of  the  city  are  specially  limited. 

Interviews  with  a  number  of  foreign-born  physicians  revealed  a  consider- 
able feeling  that  they  "hadn't  had  a  chance."  A  list  of  63  foreign -born 
physicians  in  Cleveland,  furnished  by  one  of  the  organizations  interested  in 
immigrants,  is  probably  considerably  less  than  the  actual  number.  Many 
of  these  physicians  have  a  large  practice  among  groups  of  immigrants  and 
their  children,  who  constitute  a  considerable  proportion  of  the  population 
of  Cleveland.  Only  nine  of  these  63  physicians  were  found  to  be  on  the 
lists  of  any  of  the  hospital  staffs.  The  foreign-born  physicians  of  the  more 
recent  groups  of  immigrants,  such  as  the  Slavic  and  Italian  peoples,  are 
practically  unrepresented.  It  may  be  felt  by  many  that  such  a  condition 
will  tend  to  take  care  of  itself  with  time.  However,  the  unstimulated  move- 
ment of  "time"  is  too  slow.  A  definite  effort  should  be  made  to  give  recog- 
nition on  hospital  or  dispensary  staffs  to  physicians  of  good  standing  who 
are  of  foreign  birth  or  descent,  particularly  in  institutions  which  number 
among  their  patients  large  numbers  of  the  foreign-born.  As  has  appeared 
in  the  section  discussing  "The  Human  Problem  of  the  Hospital  Patient," 
(pages  849-857),  a  number  of  the  hospitals  fall  into  this  group.  There  is 
unusual  value  in  dispensary  service  rendered  by  well-selected  physicians  of 
this  type. 

Physicians  of  the  Negro  race  constitute  a  small  but  definite  group  whose 
opportunities  to  work  in  medical  institutions  of  Cleveland  have  been  greatly 
restricted.  There  are  said  to  be  19  Negro  physicians  in  Cleveland.  One 
of  these  men  is  on  the  dispensary  staff  of  Lakeside  Hospital.  Representa- 
tions made  to  the  Survey  by  physicians  and  laymen  of  standing  among  the 
colored  people  of  Cleveland  are  to  the  effect  that  the  negro  physicians  and 
the  negro  people  feel  the  deprivation  brought  about  by  lack  of  member- 
ship on  the  staffs  of  hospitals  and  dispensaries.  The  problem  can  be  dealt 
with  only  in  one  way,  by  determining  that  appointments  shall  be  based 
solely  upon  merit.  It  is  a  fine  testimony  to  the  spirit  and  policy  of  the  hos- 
pitals of  Cleveland  that  so  far  as  negro  patients  are  concerned,  there  has 
been  absolutely  no  complaint  by  the  Negroes  about  discrimination.  The 
establishment  of  a  special  hospital  for  colored  people  is  believed  to  be  unneces-1- 
sary  and  undesirable. 

Perhaps  the  most  important  relation  of  hospital  and  dispensary  to  the 
medical  profession  is  their  educational  function.  The  hospital  and  dis- 
pensary represent  to  the  physician  an  opportunity  to  raise  the  practice  of 
medicine  to  a  higher  power  because  they  bring  under  his  command  the  use 
of  equipment,  the  organized  professional  skill  of  specialists,  and  technical 
assistance  such  as  are  very  rarely  available  in  private  practice,  and  then 
only  to  the  rich. 

The  educational  function  of  the  hospital  and  dispensary  is  only7  in  part 
exercised  through  medical  schools.  The  teaching  of  a  medical  school  like 
that  of  Western  Reserve  University  depends  in  a  large  measure  upon  the 


864  Hospital  and  Health  Survey 

hospitals  and  dispensaries  which  are  affiliated  with  the  school.  Under- 
graduate teaching  is  and  in  general  can  most  advantageously  be  limited 
to  a  few  selected  hospitals.  The  development  of  post-graduate  instruction 
under  the  medical  school  in  the  general  and  special  branches  should  pro- 
ceed at  a  rapid  rate  in  the  near  future,  and  should  involve  the  use  of  a  con- 
siderable additional  number  of  hospitals  and  clinics. 

The  actual  value  of  the  hospital  as  a  place  of  advancing  medical  science 
and  of  the  skill  of  the  local  profession  depends  of  course  largely  upon  the 
use  made  of  the  advantages  offered.  Decidedly  one  of  the  most  important 
means  of  self-criticism  which  a  member  of  a  hospital  staff  can  have  is  the 
autopsy.  Definite  knowledge  concerning  the  disease  which  caused  the  death 
of  a  patient  can  very  frequently  be  obtained  by  autopsy  as  in  no  other  way. 
It  is  disappointing  to  find  that  according  to  reports  received  by  the  Hospital 
Council  during  the  year  1919,  only  456  autopsies  were  performed.  Reports 
from  some  hospitals  were  a  little  indefinite,  and  the  true  number  might 
have  been  slightly  larger.  The  figures  and  details  are  shown  in  the  following 
table. 

Autopsies  Performed  in  1919  in  Certain  Hospitals 

City (approximately)  209             Mt.  Sinai _ 50 

Fairview. 0             Provident 0 

Glenville 1  St.  Alexis .number  unknown 

Grace number  unknown             St.  Ann's 20 

Huron  Road 5             St.  Clair 1 

Lakeside 110             St.  John's 20 

Lakewood number  unknown             St.  Luke's _ 5 

Lutheran 0             St.  Vincent's 27 

Maternity 8             Woman's 0 

Total - 456 

Such  a  low  percentage  can  only  mean  one  of  two  things — either  failure 
on  the  part  of  the  medical  staff  to  appreciate  the  importance  of  autopsies, 
as  a  real  checking  up  of  results,  and  setting  a  real  standard  of  self-criticism 
and  self-improvement,  or  on  the  other  hand,  a  lamentable  deficiency  in 
administration,  in  failing  to  endeavor,  in  each  case  of  death,  to  secure  if 
possible  consent  for  autopsy  from  the  family  of  the  patient.  Experience  in 
many  hospitals  in  other  communities  shows  that  it  is  necessary  to  fix  re- 
sponsibility upon  some  definite  person  for  each  branch  of  service,  usually 
on  the  senior  resident  or  interne,  for  securing  permission.  Compliance  with 
the  spirit  as  well  as  with  the  form  of  the  standards  of  the  American  College 
of  Surgeons  demands  that  the  medical  profession  for  its  own  sake  show 
better  results  in  the  future  in  securing  autopsies  in  the  hospitals  of  Cleveland. 
It  is  recognized  that  the  public  needs  education  to  understand  the  great 
value  of  autopsies,  not  only  for  the  physician,  but  in  the  long  run  to  improve 
the  treatment  of  every  patient. 


Percentage  of 

opsies 

Deaths 

autopsies  to  deaths 

209 

861 

24.3 

110 

320 

34.4 

50 

188 

27.1 

27 

331 

8.2 

Hospitals  and  Dispensaries  865 

It  is  particularly  interesting  to  observe  that  the  three  teaching  hos- 
pitals (City,  Lakeside,  and  St.  Vincent's),  together  with  Mount  Sinai,  show 
396  autopsies  out  of  a  total  of  456.  Taking  these  four  hospitals,  the  number 
of  autopsies  compared  with  the  number  of  deaths  is  shown  in  the  following 
table.  It  will  be  observed  that  the  best  showing  made  is  of  only  about 
one-third  of  deaths  autopsied,  and  that  the  average  even  of  these  hospitals 
i  s  less  than  25  per  cent. 

Autopsies  and  Deaths,  Compared,  1919,  in  Four  Hospitals 


City 

Lakeside 

Mt.  Sinai 

St.  Vincent's 

Totals 396  1,700  23:3 

Beyond  the  formal  courses  recognized  as  such  under  the  medical  school, 
however,  the  broader  educational  function  of  the  hospital  and  dispensary 
ought  to  be  fulfilled.  Monthly  staff  meetings  for  the  discussion  of  cases, 
review  of  hospital  statistics,  and  of  the  result  of  operation  or  treatment,  are 
valuable  means  whereby  the  physician  and  the  hospital  are  stimulated,  and 
the  service  of  the  institution  is  advanced.  The  participation  of  an  auxiliary 
staff  should  be  of  much  educational  value.  The  daily  contact  of  physicians 
with  one  another  in  the  clinics  of  the  dispensary  and  in  the  wards  is  a  less 
formal  but  no  less  effective  means  for  development  of  knowledge  and  skill. 
Finally,  the  opening  of  facilities  for  diagnostic  service  to  the  physicians  of 
a  community  on  a  broad  scale,  through  diagnostic  clinics,  and  larger  pro- 
vision for  treatment  of  private  patients,  should  serve  to  render  the  medical 
educational  functions  of  the  hospitals  and  dispensaries  effective  over  a  much 
wider  range  and  to  a  more  profound  degree. 

Medical  Staff  Organization* 

(a)  The  members  of  the  Medical  Executive  Committee  should  include 
the  chiefs  or  representatives  of  the  division  of  medicine  and  surgery,  one  or 
more  representatives  of  the  specialties,  and  a  representative  from  the  assist- 
ants or  junior  members  of  the  staff. 

(b)  The  Medical  Staff  should  establish  standards  of  hospital  practice 
in  all  departments,  including  laboratories,  X-Ray  department,  etc.  All 
Medical  Staffs  should  take  official  action  by  resolution  or  pledge  in  the 
matter  of  fee  splitting.  No  member  of  the  Medical  Staff  should  hold  mem- 
bership  on   the   Board   of   Trustees.     Privately   organized   hospitals   with 

*By  W.  L.  Babcock,  M.  D.     Reference  should  be  made  to  pages  845-848,  to  which  this  is  a  supple- 
ment. 


866  Hospital  and  Health  Survey 

Boards  of  Trustees  consisting  of  medical  men  should  reorganize  by  arranging 
for  the  appointment  of  a  lay  Board  of  Trustees,  the  physicians  interested 
in  the  hospital  organizing  into  an  Attending  Staff.  The  senior  Attending  Staff 
physicians  should  hold  active  staff  membership  in  one  hospital  only.  This 
restriction  should  not  apply  to  members  of  the  staff  engaged  in  university 
teaching,  or  to  specialists  with  limited  services,  or  in  small  hospitals  to 
clinical  assistants. 

(c)  The  following  additional  committees  will  often  be  found    useful: 

Library  Committee. 

Resident  House  Staff  Committee. 

Hospital  Records  or  Program  Committees. 

(d)  Provisions  should  be  made  for  the  recognition  of  non-staff  physicians 
by  permitting  the  use  of  a  limited  number  of  hospital  beds  under  the  general 
supervision  of  the  Chief  of  the  Medical  Staff  through  Chiefs  of  Departments. 
It  should  be  recognized  that  the  so-called  open  hospital  is  a  powerful  factor 
in  preventive  medicine,  a  post-graduate  school  for  the  general  practitioner, 
and  a  great  influence  towards  his  professional  elevation.  The  practice  of 
non-staff  physicians  in  hospitals  should  be  regulated,  scrutinized  and  carefully 
supervised  by  the  Executive  Committee. 

(e)  The  stand  taken  by  the  Cleveland  Hospital  Council  to  the  effect 
that  all  hospital  bills  should  be  paid  before  the  Attending  Physician  or  Sur- 
geon collects  his  bill  is  to  be  commended  and  should  be  made  a  rule  in  every 
hospital. 

(f)  At  least  ten  staff  meetings  should  be  held  annually,  at  monthly 
intervals,  excluding  July  and  August.  As  many  more  may  be  called  as  are 
deemed  necessary.  The  Executive  Committee  should  meet  monthly  or 
oftener.  Regular  Staff  Meetings  should  be  90  per  cent,  clinical.  Routine 
business  should  be  abbreviated  and  parliamentary  discussions  avoided, 
except  on  important  matters  of  staff  or  hospital  policies.  Provision  should 
be  made  by  the  Record  Committee,  or  otherwise,  for  review  of  clinical  records. 
Reports  of  unusual  or  interesting  cases  should  be  presented  for  group  dis- 
cussion, together  with  results  of  original  research  work  carried  out  by  indi- 
vidual members  of  the  staff,  or  the  hospital  laboratories.  It  is  also  desirable 
that  arrangements  be  made  to  serve  light  refreshments  after  these  staff 
meetings,  which  must,  of  necessity,  be  held  in  the  evening.  It  has  been 
shown  in  at  least  one  instance  where  this  program  has  been  carried  out  for 
years  that  the  percentage  of  staff  attendance  has  averaged  75  to  80  per  cent. 


Hospitals  and  Dispensaries  867 

of  staff  membership  and  has  exceeded,  by  several  hundred  per  cent.,  the 
attendance  at  regular  meetings  of  the  County  Medical  Society.  Attention 
is  called  to  the  recommendations  of  the  American  College  of  Surgeons  as  to 
program  for  staff  meetings.  The  Associate,  Auxiliary  and  Resident  Staffs 
should  meet  with  the  Attending  Staff  at  their  monthly  clinical  meetings. 


868  Hospital  and  Health  Survey 


FINANCES  AND  ADMINISTRATION 

To  maintain  the  21  institutions  which  are  members  of  the  Cleveland 
Hospital  Council  cost  nearly  three  million  dollars  during  1919.  About  97 
per  cent,  of  this  was  for  hospital  care  and  %Yl  to  3  per  cent,  for  dispensary 
service.*  This  $3,000,000  represents  about  700,000  days  of  hospital  care 
given,  and  120,000  dispensary  visits.  It  represents  service  to  probably 
80,000  different  individuals.  In  other  words,  these  hospitals  and  dispen- 
saries care  for  one  person  out  of  every  twelve  in  the  population  of  greater 
Cleveland,  and  cost  about  $3.07  for  each  member  of  the  population.  Only 
a  fraction  of  this  cost,  however,  is  a  net  charge  upon  the  community,  for  as 
the  third  column  of  Table  VI.  indicates,  the  operations  of  the  institutions 
yielded  a  very  considerable  portion  of  the  necessary  income. 

Over  two-thirds,  in  fact,  of  the  expense  of  the  non-municipal  hospitals  i  s 
repaid  by  fees  from  patients  and  by  other  earnings.  The  other  third,  or 
between  $600,000  and  $650,000,  has  to  be  provided  by  interest  on  endow- 
ments, by  legacies  and  gifts  from  the  public.  Taxation  must  provide  for  the 
municipal  institutions  to  approximately  the  same  amount.  It  will  be  ob- 
served that  in  these  figures  relating  earnings  to  expenditure,  only  the  non- 
municipal  hospitals  are  considered.  While  there  are  some  earnings  in  the 
municipal  institutions,  they  cannot  fairly  be  compared  with  the  other  hos- 
pitals in  this  respect. 

The  non-municipal  hospitals  bring  upon  the  public  an  annual  charge  of 
approximately  $460,000,  after  deducting  from  the  total  expense  the  earnings 
from  patients  and  the  amount  available  from  endowments  of  various  sorts. 
This  figure  is  the  estimate  for  the  year  1920,  as  presented  to  the  public  in  the 
Community  Chest  campaign  of  November,  1919.  The  City  Hospital,  to- 
gether with  Warrens  ville  Tuberculosis  Sanatorium,  required  in  1919  an 
appropriation  of  $625,656.92  from  taxation.  Adding  together  the  cost  for 
the  municipal  and  the  non-municipal  hospitals,  we  find  that  $1,086,000  is  the 
approximate  amount  required  to  maintain  the  hospitals  and  dispensaries  of 
Cleveland,  in  annual  contributions  by  the  public  or  "voluntary"  taxation, 
taken  together  with  legal  or  compulsory  taxation.  This  is  about  $1.30  for 
every  man,  woman,  and  child  in  the  city  of  Cleveland,  or  about  $1.10  per 
head  if  the  larger  metropolitan  area  which  these  hospitals  serve  is  taken 
into  consideration. 

Parenthetically,  it  should  be  noted  that  these  figures  do  not  include  the 
cost  of  the  dispensary  "Health  Centers"  maintained  by  the  Division  of 
Health,  the  cost  of  the  city  physicians  who  care  for  the  sick  in  their  homes, 
or  any  of  the  other  expenses  of  the  Division  of  Health.  In  the  main,  the 
bulk  of  these  vast  sums  goes  for  the  care  of  sickness.  The  total  amount 
expended  for  education  in  hygiene  and  for  the  prevention  of  disease  is  only 
a  fraction  of  this  amount,  the  expenditure  for  the  Division  of  Health  being 
less  than  50  cents  per  capita.     Expenditures  for  hospitals    are  necessary 

♦The  cost  of  the  dispensaries  is  not  accurately  stated  in  several  of  the  hospital  reports,  and  the  above 
figure  is  therefore  an  estimate,  merely. 


Hospitals  and  Dispensaries  869 

and  desirable  under  present  conditions,  but  one  may  look  forward  to  a  day 
when  the  proportion  between  the  expenditure  to  cure  illness  and  expenditure 
for  prevention  will  not  be  so  heavily  weighted  against  the  preventive  measures. 

The  cost  of  hospital  service  is  more  accurately  expressed  in  terms  of  the 
unit  previously  defined;  namely:  average  cost  per  day  of  care.  As  will  be 
seen  at  the  foot  of  Table  VI.,  this  average  cost  for  a  large  group  of  the  non- 
municipal  hospitals  was  approximately  $4.39  in  1919. 

Hospitals  have  felt  keenly  the  high  cost  of  living,  more  heavily  in  fact 
than  most  institutions,  because  of  the  large  proportion  of  their  expenditure 
which  goes  for  food,  drugs,  and  supplies  of  all  kinds,  which  have  especially 
increased  in  price  during  the  past  few  years.  The  public  has  not  appre- 
ciated how  expensive  good  hospital  service  must  now  be. 

When  individual  hospitals  are  compared,  the  average  cost  stated  in  their 
reports  for  the  year  1919  varied  from  $2.00  to  $5.62.  This  range  is  doubt- 
less too  wide,  in  that  it  is  not  believed  the  lower  rate  is  a  true  representation 
of  the  cost  of  any  hospital.  Accounting  systems  have  not  always  been  de- 
signed so  as  to  charge  to  annual  maintenance  all  the  items  which  should 
properly  be  so  entered.  It  is  not  believed  at  the  present  time  that  any  mem- 
ber of  the  Hospital  Council  is  maintaining  service  at  a  rate  less  than  $3.00 
per  diem,  and  this  figure  is  too  low  to  render  adequate  service  under  present 
conditions.  A  general  hospital  properly  equipped  should  expect  a  per  capita 
cost  of  fully  $4.00  per  diem.  When  a  hospital  is  rendering  an  unusual  grade 
of  service  or  is  conducting  medical  teaching  or  research,  a. cost  of  $5.00  a 
day  need  not  excite  objection. 

In  general,  the  average  cost  of  a  day's  care,  or  the  so-called  "hospital  per 
capita, "  must  be  used  with  great  caution  as  a  basis  for  either  commendation 
or  criticism.  It  must  be  known  how  the  per  capita  cost  is  made  up — whether 
for  instance  a  low  per  capita  is  due  to  undue  crowding,  whether  a  high  per 
capita  has  been  due  to  a  small  number  of  bed  days  care  given  because  of  tem- 
porary lack  of  demand  or  enforced  closing  of  certain  wards  or  rooms,  or 
whether  a  high  per  capita  is  due  to  unusual  quality  of  service,  or  on  the 
other  hand  to  uneconomical  administration,  or  again  whether  a  low  figure 
may  be  accounted  for  by  careful,  economical  administration,  or  else  by  the 
lack  of  the  proper  facilities. 

As  a  rule,  many  different  elements  must  be  known  and  considered  before 
forming  any  judgment  as  to  the  significance  of  a  given  per  capita  cost.  The 
average  for  the  city  as  a  whole  is  of  considerable  general  interest,  particu- 
larly in  view  of  the  need  to  call  public  attention  to  the  expensiveness  of 
modern  hospital  service.  The  fact  that  hospitals  have  been  generally 
charging  ward  rates  (at  least  until  very  recently)  as  low  as  $2.00  per  diem  is 
a  little  misleading.  The  average  person  has  somehow  taken  for  granted 
that  if  a  patient  paid  the  so-called  ward  rate,  the  hospital's  cost  was  met. 
This  is  far  from  the  truth.  Ward  rates  have  generally  been  put  far  below 
cost,  and  in  recent  years,  most  of  the  hospitals  of  Cleveland  have  failed  to 
raise  ward  rates  to  correspond  with  the  increase  in  expense.     This  has  been 


870  Hospital  and  Health  Survey 


due  in  considerable  measure  to  a  desire  not  to  levy  a  tax  upon  the  sick  and 
suffering,  or  to  make  known  rates  which  might  keep  needy  patients  from 
the  hospital  doors. 

Time  was  when  hospitals  were  thought  of  as  charities  for  the  destitute, 
but  at  the  present  time,  hospitals  are  public  services  receiving  the  well-to-do 
and  middle  classes  as  well  as  the  poor,  in  varying  proportions.  The  general 
public  should  be  brought  to  the  point  of  understanding  that  hospital  ser- 
vice ought  to  be  paid  for  at  its  cost  by  those  who  are  able  to  pay,  and  that 
room  and  ward  rates  should  be  adjusted  with  respect  to  cost  of  service. 
Considering  the  fact  that  a  hospital  of  the  public  service  class  often  has  an 
endowment,  it  should  be  expected  that  the  income  from  the  endowment  will 
go  to  help  make  up  the  difference  between  the  cost  of  service  and  the  earn- 
ings from  operation.  A  deficiency  will  be  due  partly  to  the  fact  that  the 
ward  rates  are  put  at  less  than  cost,  and  partly  to  the  fact  that  many  patients 
should  be  and  are  accepted  who  cannot  pay  even  these  rates. 

As  a  general  principle,  ward  rates  ought  to  be  fixed  somewhat  below  the 
cost  of  service,  but  not  very  much  below.  It  is  believed  wise  that  at  the 
present  time  the  hospitals  of  Cleveland  should  not  announce  rates  for  ward 
service  at  less  than  $3.00,  and  in  many  hospitals  or  in  some  divisions  thereof, 
ward  rates  may  be  $3.50  a  day.  The  naming  of  these  rates  in  no  case  should 
imply  that  patients  unable  to  pay  them  in  part  or  able  to  pay  nothing  should 
be  refused  admission.  A  hospital  cannot  expect  financial  support  from  the 
public  unless  it  makes  the  patient's  need  and  not  the  patient's  means  the 
basis  on  which  service  is  offered  and  rendered. 

In  the  following  section  of  this  Chapter  (pages  877-889)  Dr.  W.  L.  Bab- 
cock  has  outlined  a  large  number  of  highly  practical  suggestions  and  recom- 
mendations regarding  administration.  Many  of  these  relate  to  finances. 
It  is  only  fair  to  point  out  that  the  Cleveland  Hospital  and  Health  Survey, 
despite  evident  eagerness  on  the  part  of  all  members  of  the  Hospital  Council 
to  cooperate,  found  it  no  easy  matter  to  secure  many  of  the  fundamental 
financial  and  statistical  figures  from  a  number  of  hospitals.  There  was  no- 
where lack  of  willingness,  but  the  accounts  had  not  been  kept  with  a  view 
to  critical  self -analysis. 

Methods  of  hospital  cost  accounting  have  been  pretty  thoroughly  worked 
out  during  recent  years.  Many  smaller  hospitals  feel  that  they  cannot 
readily  maintain  the  trained  book-keeping  staff  to  carry  out  a  cost  account- 
ing system.  The  extra  time  required  by  such  a  system  and  the  extra  expense 
involved  seem  too  much,  and  the  hospital  is  likely  to  go  without.  In  the 
long  run,  good  cost  accounting  is  a  money  saving  enterprise.  It  points  the 
way  to  more  economies  than  its  own  maintenance  costs.  It  also  helps  in 
fixing  rates  so  that  they  bear  proper  relation  to  cost,  and  tends  to  increase 
income  where  income  needs  to  be  increased. 

The  needs  of  the  smaller  hospitals  can  be  met  only  by  some  cooperative 
enterprise.  The  Welfare  Federation  should  establish  an  expert  accountant 
service,  available  to  any  of  the  Cleveland  Hospital    Council    members,    for 


Hospitals  and  Dispensaries  871 

service  in  the  administration  of  proper  accounting  systems  and  for  advice 
periodically  or  whenever  necessary  in  its  maintenance.  Such  a  plan  would 
make  available  to  all  hospitals  a  grade  of  accountant  service  which  few  if 
any  could  afford  to  maintain  alone.  The  plan  would  have  the  further  great 
advantage  of  enabling  uniform  financial  reports  to  be  periodically  rendered 
to  the  individual  boards  of  trustees,  to  the  central  budget -making  authori- 
ties of  the  Welfare  Federation  and  to  the  public,  which  in  the  long  run  foots 
the  bills. 

In  matters  of  financial  as  well  as  medical  service,  trustees  need  to  de- 
termine exactly  what  figures  they  need  to  have  presented  to  them  in  their 
annual  or  monthly  reports,  in  order  that  they  shall  know  all  they  need  to 
know  regarding  the  work  of  the  hospital.  The  central  accounting  system 
proposed  would  be  of  great  constructive  value  to  every  board  of  trustees, 
not  only  in  furnishing  information,  but  in  helping  them  to  see  what  infor- 
mation they  need  to  have  furnished.  An  X-Ray  department,  for  instance, 
is  very  expensive  to  maintain  in  terms  of  gross  expense,  but  in  many  hos- 
pitals a  considerable  proportion  of  the  X-Ray  work  is  for  patients  who  can 
pay  a  fair  fee,  so  that  the  net  expense  of  maintaining  the  department  is  not 
large.  In  a  hospital  doing  a  large  proportion  of  its  work  for  patients  who  can 
pay  few  if  any  fees,  conditions  are  different,  but  in  any  hospital,  proper  ac- 
counting will  show  just  what  the  X-Ray  department  costs,  just  what  ratio 
the  income  derived  from  it  in  its  different  classes  of  work  bears  to  the  expense 
thereof,  and  the  trustees  will  be  able  to  judge  at  the  end  of  a  month  or  a 
year  how  much  net  charge  this  service  brings  according  to  the  character  of 
work  and  service  rendered,  and  the  rates  which  patients  can  reasonably  be 
expected  to  pay. 

Perhaps  the  most  fundamental  need  for  trustees  is  to  appreciate  that  hos- 
pitals are  public  services  in  the  broad  sense  of  the  word.  Two  more  or  less 
opposite  conceptions  have  dominated  hospitals:  (1)  that  represented  in  its 
extreme  form  by  the  proprietary  hospital  treating  private  patients  where 
financ'al  return  from  the  patient  is  largely  used  in  determining  his  accepta- 
bility, (2)  the  charitable  corporation  in  the  old  sense  of  the  term,  according 
to  which  hospitals  are  regarded  as  rendering  benefits  to  the  helpless  who 
neither  can  or  should  be  expected  to  make  any  financial  return.  At  these 
two  extremes  we  would  find  hospitals  serving  private  patients  only,  and 
hospitals  serving  only  the  poverty  stricken  and  the  destitute.  The  outstand- 
ing development  in  the  relation  of  hospitals  to  the  community  during  the 
last  decade  or  so  has  been  the  increase  in  hospital  demand  by  persons  of 
the  middle  classes,  the  self-supporting  families  of  moderate  means  in  fairly 
comfortable  financial  condition  but  with  no  large  property  holdings  and  no 
large  annual  margin  of  income  over  expenditure.  These  so-called  middle 
classes  are  more  and  more  finding  that  it  is  better  to  go  to  the  hospital  than 
to  be  treated  at  home  in  serious  illness,  surgical  operation,  or  for  maternity 
care. 

Much  testimony  has  been  received  in  Cleveland  that  there  is  great  de- 
mand for  beds  for  these  middle  classes.  Beds  are  demanded  in  private  rooms 
or  more  particularly  in  two  to  four-bed  rooms  or  small  wards,  where  fees 


872  Hospital  and  Health  Survey 

will  be  moderate  and  service  excellent  but  not  of  what  may  be  called  the 
exclusive  type. 

The  hospitals  of  Cleveland  face  such  large  financial  obligations  in  view 
of  the  high  cost  of  living  that  much  anxiety  has  been  felt  by  many  trustees 
in  looking  forward  to  the  future.  Generous  public  support  for  the  hospitals 
through  the  Community  Fund  or  in  other  ways  is  indeed  necessary,  but  the 
enlargement  of  the  hospital  facilities  of  Cleveland,  particularly  in  providing 
more  fully  for  the  middle  classes,  will  assist  the  hospitals  financially  by 
rendering  a  larger  proportion  of  their  services  of  a  self-supporting  nature, 
and  thus  help  in  carrying  a  general  overhead  which  in  itself  is  a  very  consider- 
able part  of  modern  hospital  expenditure. 

The  Cleveland  Hospital  Council  is  to  be,  congratulated  for  having  re- 
cently secured  from  the  Industrial  Commission  of  Ohio,  a  more  satisfactory 
recognition  of  the  hospital's  service  to  industrial  accident  cases.  In  Ohio, 
as  in  many  other  states,  the  establishment  of  workmen's  compensation  took 
place  without  adequate  recognition  of  the  large  part  that  hospitals  and  dis- 
pensaries would  need  to  play  in  its  successful  administration.  Industries 
and  insurance  companies  found  that  prompt  and  competent  medical  assist- 
ance to  men  who  had  met  with  industrial  accidents  was  not  only  humane 
but  was  good  business.  The  promptest  possible  return  of  the  employe  to 
his  work  stops  the  weekly  payments  and  saves  more  money  than  it  costs. 
There  are  no  theoretical  or  practical  reasons  why  hospitals  which  are  sup- 
ported by  the  community  as  public  service  enterprises  should  render  any 
service  to  industry  for  less  than  the  service  costs,  when  under  the  very  foun- 
dation principles  of  workmen's  compensation,  the  industry  is  supposed  to  be 
paying  the  full  amount  of  the  bill  for  industrial  accidents.* 

Hospitals  supported  by  the  community  must  necessarily  receive  and 
care  for  many  patients  who  are  properly  public  charges  of  the  city  or  county 
or  of  some  other  county.  It  is  fair  and  desirable  that  hospitals  be  reimbursed 
for  the  care  given  patients  who  are  proper  charges  upon  the  public.  Since 
the  city  of  Cleveland  maintains  its  own  hospital,  the  City  Hospital  is  natur- 
ally the  first  place  to  which  such  patients  should  be  sent,  but  because  of 
emergency  or  other  reasons,  other  hospitals  will  necessarily  receive  cases 
which  are  charges  upon  the  city  or  county.  The  law  as  recently  amended 
renders  it  proper  for  the  Commissioners  of  Cuyahoga  County  to  reimburse 
institutions  furnishing  care  to  persons  who  are  public  charges. f  It  is  be- 
lieved that  the  following  principles  should  govern  the  administration  of  this 
provision : 

1 .  A  policy  of  paying  privately  owned  and  supported  institutions  for  services  such  as 
the  care  of  the  dependent  sick,  which  is  a  public  function  and  a  means  of  preventing  disease 
and  dependency,  instead  of  providing  adequate,  publicly  owned  and  operated  hospitals 
out  of  the  general  tax  rate  of  the  city,  is  essentially  unsound  and  should  be  condemned  as 

•Through  the  efforts  of  the  Hospital  Council  the  State  Commission  adopted  the  principle  of  "hospital 
cost  for  service  rendered"  on  July  1,  1920. 

fThe  Hospital  Council  has  already  negotiated  with  the  County  Commissioners  on  this  subject  and 
negotiations  are  encouraging. 


Hospitals  and  Dispensaries  873 


offering  temptations  to  the  political  use  of  public  monies,  and   as  contrary  to  the  spirit  of 
municipal  government. 

2.  Notable  instances  of  abuse  of  the  practice  of  subsidizing  private  hospitals  and  other 
privately  owned  institutions  are  to  be  found  in  the  recent  history  of  the  state  of  Pennsyl- 
vania. In  certain  cities,  however,  notably  Detroit,  Michigan,  and  New  York  City,  pay- 
ment to  private  institutions  for  the  care  of  public  charges  has  served  a  useful  purpose 
and  has  been  honestly  administered. 

3.  Only  as  a  temporary  expedient  and  under  strict  and  exact  determination  of  the 
quality  and  quantity  of  services  rendered  for  which  payment  is  made  can  such  a  practice 
be  approved  for  the  city  of  Cleveland. 

4.  With  the  city  definitely  committed  to  the  construction  and  maintenance  of  a 
modern  City  Hospital,  the  facilities  now  under  consideration  and  agreed  to  by  the  private 
hospitals  can  confidently  be  expected,  if  carried  out,  to  offer  relief  for  approximately  the 
next  twenty  years  on  the  basis  of  the  estimated  growth  of  Cleveland. 

5.  Without  urging  the  point  to  the  extent  of  asking  for  any  public  declaration  or 
commitment  by  the  Hospital  Council  to  a  policy,  it  is  thought  by  the  Survey  that  agree- 
ment should  be  reached  by  the  hospitals  in  the  Hospital  Council  to  apply  funds  for  the 
extension  of  their  facilities  for  part-pay  patients  equal  in  amount  to  the  sums  received  in 
the  year  from  the  County  Commissioners.  It  is  particularly  the  responsibility  and  privilege 
of  the  privately  owned  hospitals  to  meet  the  need  of  the  patient  of  modest  means  who 
expects  to  pay  part,  if  not  the  whole  cost  of  hospital  care.  County  payments  for  the  care 
of  the  dependent  sick  should  be  a  resource  for  increasing  part-pay  bed  capacity  and  should 
not  be  accepted  merely  as  a  relief  from  the  burden  of  raising  funds  for  meeting  current 
expenses. 

6.  With  the  understanding  that  the  full  influence  of  the  Hospital  Council  collectively 
and  through  its  component  institutions  will  be  used  to  accomplish  the  two  objects  men- 
tioned in  4  and  5  above,  and  in  the  belief  that  the  necessity  for  County  payments  to  pri- 
vate hospitals  should  cease  when  adequate  provision  for  the  dependent  sick  is  made  in 
publicly  owned  and  operated  hospital  or  hospitals,  the  Survey  endorses  the  proposed 
system  of  contracts  with  the  County  Commissioners  under  the  following  conditions: 
namely,  that  payments  by  the  County  Commissioners  to  hospitals  with  which  they  make 
contracts  shall  be  made  only  for  services  of  an  approved  quality,  provided  for  a  definite 
period  of  time  and  for  specified  individual  patients  who  have  been  shown  to  be  entitled 
to  public  relief  after  investigation  of  their  home  or  economic  condition  by  representatives 
acting  under  the  orders  of  the  County  Commissioners. 

7.  Inasmuch  as  the  County  Commissioners  cannot,  without  amendment  of  state  laws, 
employ  from  public  funds  investigators  to  ascertain  the  quality  of  services  given  to  patients 
or  to  verify  claims  of  hospitals  and  patients  that  such  and  such  individuals  are  proper 
objects  of  public  assistance,  it  is  suggested  that  the  Hospital  Council  request  the  Community 
Fund  to  put  at  the  disposal  of  the  Welfare  Federation  such  amount  from  the  unassigned 
funds  as  may  be  needed  (tentatively  estimated  as  $5,000)  to  employ  trained  social  investi- 
gators to  be  put  at  the  disposal  of  the  County  Commissioners  for  the  purpose  above  de- 
scribed. 


874  Hospital  and  Health  Survey 

8.  It  is  suggested  that  the  Hospital  Council  bind  its  members  by  mutual  agreement 
to  enter  into  contract  with  the  County  Commissioners  only  on  the  basis  of  the  conditions 
suggested  in  6. 

The  hospitals  of  Cleveland  are  in  a  fortunate  position  compared  with 
those  of  most  cities,  because  of  joint  financing  through  the  Community  Fund. 
The  needs  of  many  institutions  are  brought  before  the  public  at  a  single 
time  in  a  forceful  impressive  way.  Mutual  relationship  among  hospitals 
and  a  better  understanding  of  the  broad  needs  of  the  community  are  cer- 
tainly promoted  also.  None  the  less  does  the  work  of  each  hospital  need 
interpretation  to  the  public  which  supports  it  financially.  There  is  in- 
deed a  more  definite  demand  for  accurate  and  comprehensive  financial  re- 
ports under  such  a  system  as  exists  in  Cleveland,  since  the  central  financial 
and  appropriating  committees  of  the  Welfare  Federation  are  in  a  position 
to  scrutinize  the  financial  reports  of  each  hospital  much  more  closely  than 
the  average  contributor  will  in  communities  wherein  each  hospital  raises  its 
funds  independently.  An  added  stimulus  is  thus  applied  toward  economy 
and  toward  careful  financial  and  book-keeping  systems.  All  the  more  do 
the  hospitals  of  Cleveland,  particularly  the  smaller  ones,  need  expert  ac- 
countant service  to  enable  them  to  work  out  their  book-keeping  and  their 
financial  reports  in  the  best  way. 

The  Purchasing  Bureau  of  the  Cleveland  Hospital  Council  is  a  distinct 
and  notable  achievement,  indicative  of  the  spirit  of  cooperation  in  com- 
munity enterprises  which  is  characteristic  of  Cleveland.  Through  the  Pur- 
chasing Bureau  more  economical  and  satisfactory  buying  of  standard  hos- 
pital supplies  is  made  possible.  Each  member  of  the  Council  is  thus  pro- 
vided with  the  services  of  an  expert  in  buying,  who  is  devoting  his  entire 
time  to  studying  markets,  making  contracts  and  assisting  the  hospitals  to 
get  the  best  and  the  most  for  their  money.  It  is  to  be  regretted  that  the 
use  of  the  Bureau  by  a  number  of  hospitals  has  not  been  as  large  as  it  should 
be.  If  the  purchases  of  the  hospital  for  all  kinds  of  supplies  be  taken,  and 
the  amount  of  purchases  made  in  1919  through  the  Purchasing  Bureau,  be 
expressed  as  a  percentage  of  this,  we  have  a  certain  index  of  the  degree  to 
which  the  hospital  has  taken  advantage  of  this  measure  of  economy.  It  is 
found  that  the  percentages  of  utilization  by  the  different  hospitals  were  as 
given  in  the  following  table : 


Hospitals  and  Dispensaries  875 

Proportionate  Use  of  the  Central  Purchasing  Bureau  of  the  Cleve- 
land Hospital  Council 

Proportion  of  Maximum* 
Hospital                                       Purchasing  Possibility- 
Cleveland  Maternity l/z 

Fairview  Park.... Less  than  l/3 

Glenville... ..Approximately  4/7 

Grace l/6 

Huron  Road... l/8 

Lakeside Maximum 

Lakewood ....1/13 

Lutheran.... ._ ..1/25 

Mount  Sinai Less  than  l/3 

Provident...... __l/l2 

St.  Alexis _. l/20 

St.  Ann's .3/8 

St.  Clair l/5 

St.  John's...... l/5 

St.  Luke's .....About  1/4 

St.  Vincent's. l/l7 

Woman's Approximately  l/5 

Most  hospitals  find  it  convenient  to  make  some  purchases  independently 
from  time  to  time,  because  of  the  unusual  character  of  the  article  to  be 
bought  or  because  of  the  haste  with  which  it  must  be  secured,  but  given 
efficiency  on  the  part  of  the  Purchasing  Bureau,  these  objections  should  be 
reduced  to  a  minimum.  Furthermore,  it  is  obvious  that  the  more  fully  the 
Bureau  is  utilized,  the  larger  will  be  its  purchasing  power  and  the  better 
terms  it  can  make.  Doctor  Babcock's  recommendations  regarding  the 
Bureau  (pages  882-885)  are  very  pertinent  and  practical. 

In  this  as  in  helping  the  hospitals  to  save  money  by  getting  the  largest 
discounts  for  cash  (page  879— section  on  "Practical  Matters  of  Ad- 
ministration") the  Welfare  Federation  is  in  a  position  to  make  the  money 
contributed  by  the  public  go  further  than  it  now  does. 

Hospitals  are  likely  to  benefit  by  taking  advantage  of  every  opportunity 
for  expert  assistance  in  any  of  their  many  special  lines  of  activity.  The 
School  of  Pharmacy  of  Western  Reserve  University,  for  instance,  is  in  a 
position  to  offer  assistance  to  the  hospitals  of  Cleveland  that  would  be  of 
great  benefit  in  two  ways:  enabling  the  hospital  to  render  a  higher  type  of 

*In  1919  Lakeside  Hospital  made  practically  all  of  its  purchases,  amounting  to  exactly  one-third  of 
its  operating  expenses,  through  the  Central  Purchasing  Bureau  of  the  Cleveland  Hospital  Council.  That 
figure  has  therefore  been  adopted  as  the  maximum  purchase  percentage,  and  the  purchases  of  other  hos- 
pitals have  been  figured  on  this  basis. 


876  Hospital  and  Health  Survey 

service  to  the  public,  and  lowering  the  cost  of  medicines  to  the  hospitals. 
For  a  description  of  the  proposed  service,  see  the  section  on  Pharmacy,  in 
Part  VIII.  Such  a  plan  would  take  at  least  a  year  to  perfect,  but  its  value 
to  hospital  service  should  be  self-evident. 

Hospital  financing  and  hospital  administration  have  become  technical 
matters.  At  best,  the  average  layman  is  not  concerned  with  or  even  inter- 
ested in  their  details.  It  is  of  the  greatest  importance,  however,  that  the 
hospitals  of  Cleveland  shall  not  lose  their  individuality  because  of  joint  re- 
lations through  the  Welfare  Federation  and  the  Cleveland  Hospital  Council, 
and  that  the  work  of  each  hospital  as  well  as  of  all  hospitals  taken  together 
shall  be  properly  understood  by  the  public.  To  take  technical  reports  of 
income,  expenditure,  and  service  rendered,  as  prepared  by  the  hospital  for 
the  use  of  its  trustees,  the  Cleveland  Hospital  Council,  and  the  Welfare 
Federation,  and  to  utilize  these  reports  as  the  basis  of  an  account  of  hospital 
work  in  which  the  whole  community  will  be  interested,  is  the  duty  of  a 
"publicity  man."  The  publicity  men  and  the  Welfare  Federation  which 
provides  publicity  service,  should  constantly  bear  in  mind  that  the  public 
needs  to  be  helped  not  only  to  understand  what  hospitals  do,  but  that  their 
work  is  costly  and  why  this  is  so.  Comparisons  of  the  present  cost  of  hos- 
pital care  with  the  cost  in  former  years  will  be  useful  if  so  presented  as  to 
bring  home  to  the  reader  that  the  added  cost  is  not  only  because  of  higher 
price  levels,  but  means  also  a  higher  quality  of  service.  The  business  man 
who  thinks  in  terms  of  dollars  and  cents  needs  to  be  made  to  see  why  the 
medical  boarding  house  type  of  institution  has  a  lower  cost,  and  why  such 
low  cost  is  not  as  good  a  thing  for  the  community  as  a  hospital  costing  fifty 
per  cent,  more  per  capita  but  run  as  a  modern  hospital  with  adequate  medical, 
nursing,  and  social  service  facilities  for  diagnosis  and  treatment.  The  public 
must  learn  that  health  can  be  bought  at  a  price  and  that  the  price  is  worth 
paying. 


Hospitals  and  Dispensaries  877 

SOME  PRACTICAL  MATTERS  OF  ADMINISTRATION 
By  W.  L.  Babcock,  M.  D.5 

Consultant  on  Hospital  Administration  for  the 
Cleveland  Hospital  and  Health  Survey. 

In  making  these  statements  and  recommendations  on  General  Adminis- 
tration, it  is  recognized  that  the  Cleveland  Hospital  Council  has  had  many 
of  them  under  consideration  and  in  certain  instances  has  actually  had  com- 
mittees at  work  in  standardization  of  supplies,  uniform  records,  accounting, 
uniform  rates,  etc.  In  its  contact  with  the  administrative  departments  of 
the  hospitals  within  the  Council,  the  Cleveland  Hospital  Council  has  de- 
veloped a  working  organization  of  great  practical  benefit  to  its  members. 
The  projects  under  consideration  by  its  various  committees,  as  well  as  the 
recommendations  herein,  are  practical  and  logical  steps  in  the  develop- 
ment of  economical  administration  and  efficiency.  The  Council  would  be 
of  little  benefit  to  its  membership  unless  it  adopted  standards  that  would 
tend  to  lift  the  level  of  the  hospitals  to  an  efficient  average.  The  Council 
can  be  of  the  greatest  benefit  if  it  leads,  plans  and  organizes  in  advance  of 
the  hospitals. 

FINANCIAL 

1.  Financial  and  Office  Records,  Bookkeeping,  etc. — The  Cleve- 
land Hospital  Council  has  unified  and  standardized  the  financial  and  statis- 
tical reports  of  its  constituent  hospitals.  The  bookkeeping  systems,  forming 
the  basis  of  these  reports,  which  are  rendered  monthly,  have  not  been 
standardized  in  the  various  hospitals.  It  is  recommended  that  the  book- 
keeping forms  and  headings  used  by  the  various  hospitals  be  made  uniform. 
This  is  particularly  necessary  for  cash  blotters,  and  voucher  registers,  in 
order  to  show  similarity  in  distribution  of  earnings  and  expenses. 

The  records  furnished  the  Cleveland  Hospital  Council  relating  to  per 
capita  cost  in  some  of  the  hospitals  have  been  fallacious  from  the  begin- 
ning for  the  reason  that  many  of  the  extraordinary  expenses  of  some  of 
the  hospitals  have  been  charged  to  special  funds  and  not  to  maintenance 
accounts.  In  several  of  the  smaller  hospitals  record  of  receipts  and  expend- 
itures only  is  maintained.  No  attempt  has  been  made  by  these  hospitals 
to  credit  or  debit  the  various  departments  of  the  hospitals  with  their  earn- 
ings or  expenses.  The  per  capita  costs  reported  by  Cleveland  hospitals 
for  1919  varied  from  $2.00  to  $5.62  per  day.  In  order  to  determine  wherein 
this  difference  may  be  found,  it  is  necessary  to  check  earnings  and  expenses 
by  departments,  such  as  training  school,  laundry,  housekeeping,  building 
maintenance  and  current  repairs,  administration,  professional  care  of 
patients,  etc.  The  latter  should  be  subdivided  into  its  natural  subdivisions, 
such  as  laboratory,  X-Ray  department,  surgical  department,  house  staff,  etc. 

2.  Accounting — The  monthly  and  annual  accounting  for  all  hospitals 
should  be  made  by  an  accountant  under  the  direction  of  the  Welfare  Federa- 


878  Hospital  and  Health  Survey 

tion.  It  may  be  feasible  for  the  latter  organization  to  maintain  the  serv- 
ices of  a  paid  accountant  staff  who  could  carry  on  a  month-to-month  audit 
in  all  hospitals  within  the  Federation  and  furnish  each  Board  of  Trustees 
with  a  monthly  and  annual  accounting  statement.  If  the  recommendations 
set  forth  in  paragraph  1  are  carried  out  in  all  of  the  hospitals,  it  will  sim- 
plify the  audit  and  accounting  to  a  great  extent.  If  a  uniform  system  of 
financial  records  and  bookkeeping  is  established  for  each  of  the  hospitals 
in  the  Council,  the  time  devoted  by  auditors  on  the  books  of  some  of  the 
hospitals  could  be  reduced  50  per  cent,  or  more.  It  should  be  stated  here 
that  the  Welfare  Federation  has  provided  for  these  audits  heretofore  through 
a  firm  of  auditors.  It  is  understood  that  the  Cleveland  Hospital  Council 
is  endeavoring  to  secure  a  uniform  system  of  accounting  for  all  hospitals 
in  the  Council. 

3.  Statement  of  Earnings — The  monthly  and  annual  statements  of 
earnings  of  hospitals  should  be  based  on  cash  receipts  only.  Unpaid  per- 
sonal accounts  of  hospitals  have  no  place  in  a  statement  of  earnings.  The 
present  earnings  and  income  reported  to  the  Cleveland  Hospital  Council 
and  Welfare  Federation  from  the  various  hospitals  are  not  comparable 
for  the  reason  that  some  hospitals  base  their  statements  on  cash  receipts 
only,  while  others  include  unpaid  personal  accounts  in  their  statement  of 
earnings.     (Note  A.) 

Note  A — The  practice  of  many  hospitals  in  carrying  unpaid  personal  accounts  on 
their  balance  sheet  as  an  asset  is  misleading,  fallacious  and  wrong  in  principle.  A  vary- 
ing percentage  of  most  of  these  accounts  are  uncollectible  because  they  are  largely  accounts 
of  part-pay  patients.  If  the  statement  of  earnings  includes  cash  receipts  only,  such  open 
accounts  as  are  paid  after  the  patient  leaves  the  hospital  will  appear  in  the  statement 
of  the  month  during  which  they  are  paid.  It  is  impossible  to  estimate  the  percentage  of 
unpaid  hospital  accounts  that  are  uncollectible.  The  good  accounts  are  usually  paid 
within  a  few  days,  while  the  great  majority  of  the  remainder  are  uncollectible. 

4.  Appraisal  of  Property — An  appraisal  of  the  physical  property,  build- 
ings and  equipment,  should  be  made  of  all  Cleveland  hospitals  on  a  basis  of 
present  values.  The  reproduction  cost  of  hospital  buildings  at  the  present 
time  is  in  some  instances  at  least  100  per  cent,  higher  than  five  years  ago.  A 
proper  percentage  for  annual  depreciation  cannot  be  established  without  an 
appraisal.  It  is  also  necessary  in  order  to  determine  valuation  for  fire  insur- 
ance, etc.  It  is  possible  that  the  expense  of  an  appraisal  could  be  lessened 
if  the  Cleveland  Hospital  Council  made  a  contract  for  all  the  hospitals  rep- 
resented in  the  Council.  The  expense  could  then  be  prorated  between  the 
hospitals  according  to  property  values. 

5.  Depreciation — Depreciation  of  buildings  and  equipment  should  be 
charged  off  annually.  The  bookkeeping  system  recommended  in  paragraph 
one  should  provide  for  an  annual  depreciation  charge. 

6.  Per  Capita  Cost — All  expenditures  for  current  repairs,  new  equip- 
ment,   replacement   of   equipment   and   betterments    to    existing   buildings 


Hospitals  and  Dispensaries  879 

should  be  charged  to  maintenance  account.  The  per  capita  per  diem  cost 
of 'maintenance  will  thereby  be  placed  on  a  uniform  basis  for  all  hospitals. 
Expenditures  for  new  buildings,  and  equipment  for  new  buildings,  should 
be  charged  to  capital  expenditures.     (Note  B.) 

Note  B — The  per  capita  cost  per  diem  for  maintenance  has  been  reported  for  Cleve- 
land hospitals  as  follows: 

(a)  For  1918,  minimum,  $1.69;    maximum,  $4.60 

(b)  For  1919,  minimum,  $2.00;    maximum,  $5.62 

(Not  including  Warrensville  Infirmary  or  the  City  Hospital).  It  is  believed  that  the 
minimum  per  capitas  reported  do  not  actually  represent  the  true  per  capita  cost. 

7.  Cash  Discounts — Cash  discounts  should  be  taken  on  all  bills  where 
possible.  Experience  in  hospital  accounting  has  demonstrated  that  legiti- 
mate cash  discounts  will  represent  one-half  of  one  per  cent,  of  total  expendi- 
tures of  general  hospitals,  or  two-thirds  of  one  per  cent,  of  total  expenditures 
for  maintenance,  exclusive  of  salaries.     (Note  C.) 

Note  C- — The  practice  of  holding  bills  for  approval  of  committees  of  the  Board  of 
Trustees  or  Managers  is  pernicious  and  accounts  for  failure  to  obtain  some  cash  discounts. 
The  Board  of  Trustees  should  put  in  the  hands  of  hospital  superintendents  full  authority 
for  approving  bills  for  payment  of  all  current  expenses.  Extraordinary  expenditures 
could  be  authorized  by  the  Boards  of  Trustees  before  order  is  placed  by  superintendents. 
Hospitals  which  habitually  pay  bills  after  30,  60  or  90  days  cannot  purchase  to  good  advan- 
tage in  the  open  market,  and  have  a  poor  credit  rating.  It  may  be  necessary  for  the  Cleve- 
land Hospital  Council  to  establish  a  fund  to  cover  the  discounting  of  bills  for  smaller 
hospitals. 

8.  Rate  for  Wards  and  Rooms — Ward  rates  are  ridiculously  low,  aver- 
aging $2.00  per  day.  These  rates  should  be  raised  to  at  least  $3.00  per  day, 
which  figure  represents  only  part  cost  of  maintenance.  Private  room  rates 
in  some  hospitals  are  also  low  and  should  be  advanced.  Board  bills  for  ward 
and  room  beds  should  be  collected  one  week  in  advance  for  general  cases,  and 
two  weeks  in  advance  for  maternity  cases.  Therefore,  patient's  relatives 
should  be  billed  weekly  in  advance.  Recognition  should  be  given  the  fact 
that  wages  and  salaries  are  materially  higher  than  when  these  rates  were 
originally  established.  It  should  be  understood  that  ward  and  room  rates 
cover  bed,  board,  pupil  nursing,  interne  service  in  the  larger  hospitals,  cer- 
tain routine  and  diagnostic  services,  and  for  free  and  some  part-pay  patients, 
gratuitous  medical  attendance. 

9.  Rates — Compensation — The  rate  formerly  allowed  by  the  Ohio  State 
Industrial  Commission  for  compensation  cases  was  outrageously  low.  Such 
rates  should  be  established  on  a  basis  of  cost  of  maintenance.  $3.00  to  $3.50 
per  day,  plus  charges  for  all  extras,  will  represent  the  approximate  cost  of 


880  Hospital  and  Health  Survey 

ward  patients,  at  present.  The  Cleveland  Hospital  Council  has  taken  the 
commendable  stand  that  hospital  cost  for  hospital  service  should  form  the 
basis  for  the  establishing  of  hospital  rates  by  the  State  Industrial  Commission, 
and  it  is  gratifying  that  the  Council  has  recently  secured  recognition  of  this 
principle  from  the  Commission. 

10.  Rates  for  Municipal  and  County  Patients — The  charge  for  the 
care  of  these  patients  should  be  based  on  the  average  cost  of  maintenance 
for  the  preceding  year  and  be  a  matter  of  annual  adjustment.  It  should  be 
based  on  per  capita  per  diem  cost.  No  hospital  should  accept  a  lump  sum 
or  subsidy  from  any  municipality,  state  or  county  authorities.  Contract 
should  never  be  made  for  the  care  of  the  sick  on  the  basis  of  a  lump  sum 
annually. 

11.  Extra  Charge  Schedule — A  charge  schedule  for  extras  should  be 
adopted  by  all  hospitals,  and  charges  made  for  many  supplies  and  much  ser- 
vice that  is  now  rendered  free.  Few  Cleveland  hospitals  have  an  adequate 
extra  charge  schedule.  Hospital  clients  think  nothing  of  paying  for  all  ser- 
vices rendered  at  a  hotel  or  elsewhere.  Extra  charges  for  supplies  or  ser- 
vices for  part-pay  patients  can  be  cancelled  or  reduced  at  discretion  where 
patients  are  unable  to  pay.     The  following  schedule  of  charges  is  suggested: 

Blood  transfusion  for  private  patients $50 .  00 

Blood  transfusion  for  ward  patients 25.00 

Large  surgical  dressings 1 .  00  to  $2  .  00  each 

X-Ray  and  stereoscopic  examinations 10.00  to  $40.00 

Board  of  Special  Nurses 1 .  50  per  day  and  up 

Plaster  casts... 2 . 00  to  $1 0 . 00 

Services  of  hired  anesthetist... 5  .  00 

Nitrous  oxide  gas  and  oxygen 5  .  00  per  adm.  hour 

Salvarsan  administration... 5.00  to  $10.00 

Proprietary  drugs,  patent  medicines,  serums,  ampules 

and  special  prescriptions Cost  plus  10% 

Splints  and  surgical  appliances Cost  plus  10% 

Meals  for  relatives  of  patients. ....'.        .  75  to  $1 .  00  each 

Cots... 1 .  00  each 

Ambulance  service Cost 

First-aid  services  for  out-cases,  including  dressings 5.00  to  $10.00 

Operating-room  fee 10  .  00 

Labor-room  fee 5 .  00  to  $10  .  00 

Special  nursing Cost 

Laboratory  fees  for  Wassermann,  blood,  stomach,  fecal,  spinal  fluid  examina- 
tion, etc.,  for  private-room  patients. 


Hospitals  and  Dispensaries  881 

12.  Credit  Investigator — (a)  Large  hospitals  should  maintain  an  in- 
vestigator or  credit  man  whose  duty  it  shall  be  to  investigate  the  financial 
circumstances  of  patients.  Many  patients  are  maintained  without  cost 
who  are  able  to  pay  part  cost;  many  ward  patients  are  cared  for  at  part  cost 
who  are  able  to  pay  full  cost.  Ability  or  disability  of  ward  patients  to  pay 
for  extras  outlined  in  the  preceding  paragraph  can  be  established  by  this  in- 
vestigator. The  data  accumulated  by  the  Social  Service  department  of 
large  hospitals  should  be  available  for  the  use  of  the  office  investigator. 
It  is  not  considered  suitable  for  the  social  service  worker  or  department  to 
be  used  as  financial  or  credit  investigator  to  protect  the  business  credit  of 
the  hospital. 

(6)  It  is  recommended  that  the  Cleveland  Hospital  Council  engage  a 
credit  investigator  to  investigate  the  economic  status  of  undetermined  cases 
in  several  small  hospitals.  The  salary  and  expense  of  this  investigator  can 
be  prorated  over  several  hospitals.  It  is  believed  that  the  financial  benefit 
derived  from  the  employment  of  such  a,  man  would  be  productive  of  a  definite 
increase  in  income  to  the  hospitals.  An  alternative  would  be  the  working 
out  of  some  arrangement  with  the  local  credit  association. 

13.  Classified  Wage  and  Time  Schedule — The  project  of  the  Cleve- 
land Hospital  Council,  through  a  committee  of  Council  members,  to  standard- 
ize hospital  wages  and  hours  of  duty  covering  certain  groups  of  hospital 
employes  is  commendable  and  should  be  carried  out.  It  is  probable  that 
some  variation  in  scale  will  be  necessary  in  order  to  provide  for  the  differ- 
ence in  responsibility,  etc.,  in  certain  positions  in  large  and  small  hospitals. 
Experience  has  shown  that  wages  in  hospitals  may  be  standardized  in  the 
following  departments : 

Training    School   Department — Floor    supervisors,    ward    orderlies, 
ward  maids. 

Housekeeping     Department — Waitresses,     chamber-maids,     pantry 
girls,  cleaners  (by  the  month),  housemen  and  porters. 

Laundry  Department — Laundresses,  washmen  and  wringermen. 

Repair    Department — Carpenters,    painters,    steamfitters    and    their 
helpers,  wall  washers,  window  cleaners. 

Engineering  Department — Engineers  and  firemen. 

Ambulance  Department — Chauffeurs. 

It  would  not  be  advisable  to  extend  this  classification  as  to  wages  and 
hours  into  offices,  laboratories  or  professional  departments  which  depend 
on  specialists  or  certain  skilled  employes. 

Owing  to  the  difference  in  the  size  of  kitchens  and  variety  of  personnel 
employed  therein,  it  is  not  considered  feasible  to  classify  kitchen  employes. 


Hospital  and  Health  Survey 


14.  Discounts  in  Room  Rates  to  Privileged  Persons — The  ma- 
jority of  hospitals  in  Cleveland  give  special  rates  to  members  of  the  staff 
and  their  families,  to  graduate  nurses  of  the  hospital  and  the  clergy. 

Hospitals  with  endowments  primarily  given  for  the  benefit  of  people  of 
lower  economic  status,  should  limit  their  room  rate  discounts  to  persons  who 
give  gratuitous  service  to  the  hospital.  Such  discount  rate  should  not  be 
less  than  the1  per  capita  cost  of  maintenance. 


PURCHASING  DEPARTMENT 

1.  Central  Purchase  Bureau — The  majority  of  Cleveland  Hospitals 
can  utilize  the  services  of  the  Central  Purchase  Bureau  to  greater  advantage. 
Several  hospitals  especially  have  neglected  their  duty  and  opportunities  in 
taking  advantage  of  the  Central  Purchasing  policy.  The  Board  of  Trustees 
of  every  Cleveland  hospital  should  .satisfy  themselves  that  the  hospital 
under  their  control  takes  advantage  of  this  principle  to  a  maximum  degree. 
Their  investigation  of  the  subject  should  include  a  comparison  of  prices  paid 
by  the  Bureau  during  the  last  year  for  like  commodities  purchased  by  the 
superintendent  of  the  hospital  during  the  same  period. 

Full  advantage  of  a  central  purchasing  bureau  will  not  be  manifested 
until  the  hospitals  standardize  supplies. 

The  replies  to  questions  referring  to  the  efficacy  of  the  purchasing  de- 
partment of  the  Cleveland  Hospital  Council,  from  the  standpoint  of  the  hos- 
pitals, reveal  two  chief  criticisms : 

(a)  That   delays   in   the   delivery   of  supplies  purchased  through  the 
Bureau  are  frequent. 

(b)  That  prices  obtained  by  the  Bureau  are  in  some  instances  no  better 
than  quotations  made  the  hospital  direct. 

In  reference  to  (a) :  it  may  be  stated  that  many  delays  have  occurred 
during  the  past  year  on  account  of  slow  freight,  insufficient  production  and 
causes  beyond  the  control  of  the  Bureau.  It  is  often  necessary,  in  order  to 
obtain  the  best  prices,  to  purchase  supplies  out  of  town  that  ordinarily 
would  be  purchased  by  the  hospital  in  the  city.  It  is  believed  that  criti- 
cisms could  be  lessened  if  the  hospitals  would  anticipate  their  wants  further 
in  advance.  To  meet  this  criticism,  the  Bureau  should  make  prompt  de- 
livery a  requisite  for  the  acceptance  of  orders,  and  aim  to  consider  prompt 
delivery  in  conjunction  with  minimum  prices. 

In  reference  to  (6) :  it  may  be  stated  that  the  benefits  of  Bureau  purchas- 
ing can  be  increased  through  larger  orders.  The  nature  of  many  commodi- 
ties does  not  enable  the  central  purchasing  bureau  to  obtain  a  price  any  lower 
than  might  be  obtained  by  the  hospital.  This  fact  of  itself  should  not  pre- 
vent placing  orders  through  the  Bureau  for  most  commodities,  inasmuch  as 


Hospitals  and  Dispensaries  883 

the  Bureau's  chief  advantage  lies  in  the  placing  of  large  orders.    The  Bureau 
should  keep  hospitals  informed  of  pending  advance  in  prices. 

The  Cleveland  Hospital  Council  Purchasing  Bureau  should  systematize 
its  Quotation  Department  so  as  to  furnish  without  delay  quotations  that 
the  hospital  executive  may  use  in  comparison  with  prices  he  may  have  re- 
ceived.    To  obviate  the  lost  time  element,  the  following  should  pertain: 

(a)  Prompt  furnishing  of  quotations. 

(b)  Prompt  placing  of  orders. 

(c)  Prompt  delivery  of  goods. 

2.  "Warehousing  by  the  Bureau — It  is  not  believed  that  the  full  benefits 
of  Central  Bureau  purchasing  will  be  manifest  until  the  Cleveland  Hospital 
Council  provides  warehousing  and  storage  facilities.  Investigation  shows 
that  many  of  the  smaller  hospitals  are  buying  in  small  quantities,  or  from 
hand  to  mouth,  for  two  reasons: 

(a)  Lack  of  capital  requisite  for  carrying  goods  in  stock. 

(b)  Lack  of  storage  facilities. 

In  view  of  the  cooperative  relationship  of  the  hospitals  to- the  Cleveland 
Hospital  Council  and  the  Welfare  Federation,  the  remedy  does  not  wholly 
lie  within  the  hospitals.  Additional  storage  space  cannot  be  provided  in 
many  hospital  buildings  without  definite  building  additions.  Limited  earn- 
ing power  of  small  hospitals  precludes  the  establishment  of  a  fund  sufficiently 
large  to  carry  a  stock  of  goods. 

Investigation  and  study  of  the  cooperative  purchasing  bureau  main- 
tained under  the  auspices  of  the  Cincinnati  Community  Union  has  thrown 
new  light  on  this  subject.  The  Cincinnati  Community  Union  has  set  aside 
a  revolving  fund  of  $50,000  to  provide  for  the  expenses,  warehousing  and 
stock  for  the  charitable  organizations,  institutions  and  hospitals  of  the  city. 
Although  in  operation  only  a  few  months,  the  participants  in  this  coopera- 
tive bureau  are  enthusiastic  over  the  results.  It  is  recommended  that  the 
Cleveland  Hospital  Council  investigate  the  possibilities'  of  warehousing  to 
a  limited  extent  in  order  to  encourage  greater  use  of  the  purchasing  possibili- 
ties of  the  bureau.  It  is  believed  that  if  the  hospitals  of  Cleveland  can  be 
assured  of  immediate  delivery  from  warehouses  of  many  staple  supplies, 
their  bureau  requisitions  would  be  greatly  increased.  The  Cincinnati  experi- 
ment has  shown  that  the  capital  tied  up  in  stock  at  certain  times  has  only 
represented  a  fraction  of  the  amount  set  aside.  In  fact,  it  is  believed  that 
during  certain  seasons  of  the  year  a  part  of  the  money  set  aside  for  warehous- 
ing stock  could  be  drawing  interest  or  be  used  for  other  purposes.  In  this 
connection,  attention  may  be  called  to  the  fact  that  provided  with  warehouse 
capacity,  the  Purchasing  Bureau  of  the  Cleveland  Hospital  Council 
could  take  advantage  of  opportunities  for  seasonable  purchases  that  would 
be  neglected  or  considered  impracticable  for  hospital  executives. 


884  Hospital  and  Health  Survey 

3.  Authorization  of  Purchases— The  purchase  of  supplies  or  requisi- 
tion on  Central  Purchasing  Bureau  should  be  made  only  with  the  approval 
of  the  superintendent,  authorized  purchasing  agent  or  steward,  the  latter  of 
whom  should  be  subordinate  to  the  superintendent.     (Note  D.) 

Note  D — The  practice  of  direct  purchases  or  Bureau  requisitions  by  heads  of  depart- 
ments or  dietitians  without  the  authority  of  the  superintendent  is  pernicious  and  not 
good  business  procedure.  The  superintendents  of  certain  hospitals  first  become  familiar 
with  some  purchases  when  bills  are  received.  Marketing  in  open  markets  by  dietitians 
and  heads  of  departments  is  good  practice  when  properly  authorized  and  checked  by 
the  hospital  superintendent. 

4.  Standardization  of  Supplies — The  project  of  the  Cleveland  Hos- 
pital Council  to  standardize  the  majority  of  hospital  supplies  is  absolutely 
necessary  to  the  proper  development  and  functioning  of  the  Central  Pur- 
chasing Bureau.  Superintendents  of  hospitals  who  have  preconceived  ideas 
as  to  standards  should  come  to  an  agreement  with  the  committee  on  standard- 
ization in  order  that  they  may  participate  in  the  benefits  to  be  derived  from 
the  uniformity  of  specifications,  once  standardization  is  accomplished.  It 
will  not  be  possible  to  extend  the  principles  of  standardization  over  all  hos- 
pital supplies,  but  it  is  believed  that  the  same  can  be  extended  over  most  pro- 
visions, housekeeping  supplies  and  to  a  certain  extent  over  furnishings.  It 
is  also  recommended  that  an  attempt  be  made  to  extend  it  over  certain 
staple  drugs  and  surgical  supplies. 

5.  Storage  Facilities  and  Advance  Purchases — Hospitals  should 
aim  to  take  advantage  of  minimum  prices  that  may  be  obtained  through 

(a)  Quantity  purchases. 

(b)  Purchases  in  advance  of  needs. 

This  plan  necessitates  increased  storage  or  warehouse  capacity  for  some 
hospitals. 

Advantage  can  be  taken  of  the  markets  by  the  seasonable  storage  of  the 
following  goods:  canned  goods,  coffee,  tea,  navy  beans,  sugar,  soap,  starch, 
laundry  soda,  flour,  butter,  eggs,  dried  fruits;  and  sometimes  crockery, 
glycerin,  lard,  narcotics,  certain  bulk  chemicals,  manufactured  dry  goods,  etc. 

Sufficient  eggs  should  be  stored  in  public  warehouses  in  April,  and  butter 
in  June,  for  hospital  consumption  during  the  months  of  maximum  high  prices. 
(October,  November,  December  and  January.) 

Egg  candling  and  storage  should  be  carried  out  only  by  reputable  and 
high  class  firms  who  will  guarantee  quality  at  time  of  consumption.  Eggs 
should  never  be  stored  in  anything  but  new  cartons. 

6.  Inventories — Physical  inventories  should  be  taken  on  the  last  day 
of  each  month,  comprising  all  material  stock  in  storerooms.  The  practice 
of  most  hospitals  of  depending  on  book  inventories  is  fallacious  and  not 
justified  in  commercial  practice,  except  for  the  drug  department.     (Note  E.) 


Hospitals  and  Dispensaries  885 

Note  E — This  recommendation  comprehends  inventory  of  unissued  stock  supplies 
such  as  groceries  and  provisions,  household  supplies,  gauze  and  cotton,  dry  goods,  laundry 
supplies,  in  storeroom  awaiting  issue.  Warehouse  supplies  should,  of  course,  be  included. 
Once  the  system  of  monthly  inventories  is  established  on  standard  inventory  blanks, 
one  office  employe  assisting  the  steward  or  proper  head  of  department,  can  take  inven- 
tory and  complete  records  in  one  or  two  days,  depending  on  the  size  of  the  hospital  and 
the  amount  of  goods  carried  in  stock.  It  is  estimated  that  the  hospital  which  does  not 
carry  on  inventory  a  stock  of  supplies  equal  to  10  to  15  per  cent,  of  its  annual  purchases, 
is  not  taking  advantage  of  seasonable  purchases  or  storage  possibilities.  In  this  con- 
nection, attention  is  called  to  the  fact  that  certain  suppplies,  soaps  for  example,  improve 
in  storage,  and  that  but  few  supplies  deteriorate. 

7.  Contracts — Annual,  limited  or  quantity  contracts  should  be  sought 
for  certain  supplies;  notably  coal,  electric  lamps  and  milk  from  producers. 
It  is  strongly  recommended  that  all  hospitals  make  arrangements  to  obtain 
their  milk  supply  from  the  producer  rather  than  depend  on  commercial 
distributors. 

8.  Drugs  and  Surgical  Supplies — It  is  recommended  that  the  Cleve- 
land Hospital  Council  employ  or  develop  a  trained  drug  and  surgical  supply 
man  as  buyer.  Expert  knowledge  of  drugs  and  drug  markets,  and  a  prac- 
tical knowledge  of  the  hospital  use  of  surgical  supplies  are  qualifications  nec- 
essary. It  is  believed  that  such  a  man  could  develop  the  purchasing  in  this 
department  and  prove  a  decided  economy  after  the  department  is  organized. 

The  offer  of  the  School  of  Pharmacy  of  the  Western  Reserve  University 
to  cooperate  with  the  hospitals  of  Cleveland  in  the  standardization  and 
manufacture  of  certain  drug  supplies  is  highly  commendable.  The  hospitals 
of  Cleveland  have  an  opportunity  to  avail  themselves  of  the  use  of  a  drug 
manufacturing  laboratory  and  expert  supervision  of  their  local  drug  depart- 
ments that  is  not  vouchsafed  to  many  hospitals  in  other  cities.  It  is  under- 
stood that  the  Cleveland  Hospital  Council  has  already  taken  steps  to  take 
advantage  of  this  splendid  proposition. 

The  venereal  clinics  of  the  city  should  take  advantage  of  the  free  pro- 
vision of  arsphenamine  by  the  state. 

9.  Food  Service  and  Directing  Personnel — The  entire  food  service 
of  the  hospital  should  be  under  the  direction  of  a  trained  dietitian.  In  small 
hospitals  it  is  possible  to  combine  the  service  of  dietitian  and  housekeeper. 
In  this  connection,  it  should  be  remembered  that  trained  dietitians  may  make 
good  housekeepers  after  reasonable  experience,  but  that  housekeepers  do  not 
ordinarily  make  good  dietitians  without  special  training.  The  service  in 
employes'  and  nurses'  dining  rooms  should  be  under  the  direction  of  the 
dietitian  as  well  as  the  food  service  to  patients.  In  large  hospitals  it  is  nec- 
essary to  study  carefully  and  provide  for  the  cooperative  relationship  of 
the  steward's  department,  main  kitchens,  which  are  usually  in  charge  of  a 


886  Hospital  and  Health  Survey 

chef,  and  the  dietitian.     The  details  of  the  hospital  food  service  are  too 
intricate  to  be  covered  by  a  survey  of  this  character. 

10.  Stewards  or  Purchasing  Agents — In  large  hospitals  stewards  or 
purchasing  agents  are  necessary  in  order  to  relieve  the  superintendent  of 
many  of  the  petty  details  of  purchasing  supplies.  Where  a  steward  or 
purchasing  agent  is  employed  he  should  have  assigned  to  him  duties  and  re- 
sponsibilities similar  to  those  of  stewards  of  large  hotels. 

HOSPITAL  ECONOMICS  AND  SALVAGING 

1.  Repair  Department — Hospitals  of  over  50  beds  can  economically 
support  a  general  repair  man  for  steam  fitting,  electrical  repair  and  carpenter 
work.  The  painter,  or  painters,  should  be  employed  by  the  month.  The 
repair  department  can  be  extended  in  personnel  and  equipment  as  the  bed 
capacity  increases.  The  development  of  a  central  surgical  instrument 
repair  shop  for  the  use  of  all  hospitals  is  desirable.  These  shops  should  be 
under  the  control  of  one  or  more  of  the  larger  hospitals  or  of  the  Cleveland 
Hospital  Council.  Experience  has  demonstrated  that  surgical  instrument 
and  appliance  shops  can  be  made  self-sustaining  almost  from  the  beginning. 
Prompt,  uniform  and  satisfactory  production  at  a  lessened  cost  will  be  the 
inevitable  result.  Such  an  activity  might  well  be  included  among  the  func- 
tions of  the  central  brace  shop  as  proposed  for  the  orthopedic  center.  (See 
pages  200-201.) 

2.  Manufacturing — Manufacturing  of  certain  hospital  supplies  can  be 
extended  by  individual  hospitals  in  accordance  with  their  needs  and  the 
ingenuity  of  the  hospital  executives.  A  central  sewing  room  for  manufactur- 
ing dry  goods  should  have  a  place  in  every  hospital. 

It  is  only  necessary  here  to  call  attention  to  the  fact  that  manufacturing 
can  be  extended  without  limit  in  hospitals  that  have  the  requisite  repair 
personnel.  Some  hospitals  manufacture  fracture  beds,  bed  elevators,  wooden 
stools,  mattresses,  cotton  waste  from  recleaned  gauze,  stretcher  canvass, 
Bradford  frames,  extension  apparatus,  splints,  etc.,  without  limit.  The 
manufacturing  of  dry  goods  adaptable  to  hospital  use  is  limitless,  depending 
on  the  facilities  provided.  The  economical  manufacture  of  soap  from  grease 
is  strongly  urged,  and  can  be  carried  out  in  the  laundry  with  very  simple 
equipment.  Soap  thus  manufactured  should  be  used  for  household  clean- 
ing purposes  as  soft  soap.  Laundry  soap  should  be  manufactured  from  soap 
chips. 

3.  Waste  and  Salvaging — Lack  of  attention  to  waste  in  hospitals  is 
uniform  all  over  the  country.  It  is  not  within  the  province  of  this  Survey 
to  discuss  it.  Attention  is  called  to  the  opportunity  for  salvaging  and  sale 
of  waste  paper,  old  barrels,  waste  rubber,  old  metal,  rags,  bottles,  etc.  Sur- 
gical gauze  and  bandages  should  be  washed  and  re- washed  until  worn  out. 
It  can  then  be  reduced  to  cotton  waste  or  sold  with  rags. 

4.  Labor  Saving  Devices — Labor  saving  devices  should  be  utilized 
wherever  possible.     Electric  dish-washing  machines  are  an  economy  of  time 


Hospitals  and  Dispensaries  887 

and  labor  in  any  hospital.     In  hospitals  of  sufficient  size,  the  same  may  be 
said  of  electric  dough -mizers,  meat-cutters  and  vacuum  cleaners. 

5.  Fire  Protection — This  subject  should  be  studied  carefully  by  hospital 
trustees  and  executives  with  the  assistance  of  expert  advice.  Few  hospitals 
have  a  sufficient  number  of  fire  extinguishers,  and  where  these  are  provided, 
they  are  not  refilled  with  proper  frequency.  Only  extinguishers  approved 
by  the  Underwriters'  Association  should  be  used  and  these  should  be  re- 
filled twice  annually.  At  each  refilling,  they  should  be  labelled  or  tagged 
with  date  of  refilling. 

Standpipe  with  hose  connections,  fire  escapes,  fire  buckets  in  attic,  should 
receive  attention.  Heads  of  departments  should  be  drilled  or  instructed  in 
their  duties  in  the  event  of  a  fire.  Fire  drills  are  desirable,  but  almost  im- 
possible on  account  of  the  frequent  changing  of  employes. 

6.  Insurance  (Fire) — It  has  been  ascertained  that  many  of  the  hos- 
pitals surveyed  are  inadequately  insured  against  fire.  After  appraisal  of 
buildings,  old  policies  should  be  cancelled  and  new  policies  taken  out  on  the 
basis  of  reappraisal.  It  is  believed  that  fire  insurance  rates  are  due  to  ad- 
vance and  it  is  recommended  that  appraisals  be  made,  old  policies  cancelled 
and  new  policies  issued  so  as  to  take  advantage  of  present  rates.  Itfis 
preferable  that  hospital  insurance  policies  be  drawn  for  five-year  periods, 
which  provide  for  lower  rates.  Co-insurance  policies  are  not  recommended 
except  for  fire-proof  buildings.  For  non-fire-proof  buildings  a  maximum  cov- 
erage is  recommended  by  means  of  straight  policies.  The  contents  of  hospital 
buildings  should  be  fully  insured  as  most  hospital  fires  are  small  and  the 
contents  suffer  to  a  greater  degree  than  the  buildings.  Owing  to  the  recent 
rapid  increase  in  construction  cost,  hospitals  should  examine  their  fire  insur- 
ance policies  without  delay  and .  increase  them  to  a  figure  approximating 
present  values. 

Compensation  insurance  covering  employes  should  be  carried  by  all 
hospitals.     Elevators  and  automobiles  should  also  be  properly  covered. 


GENERAL  RECOMMENDATIONS 

Professional 

1.  It  is  recommended  that  standing  house  orders  be  established: 

(a)  For  preparation  of  patients  for  operation. 

(b)  For  after-care  of  surgical  cases. 

(c)  For  preparation  of  patients  for  confinement  and  after-care  (pre- 
natal orders);    (post-natal  orders). 

(d)  For  preparation  of  patients  for  operation  and  after-care  in  tonsil- 
lectomy. 

2.  That  large  hospitals  sterilize  and  manufacture  prepared  catgut  from 
raw  catgut. 


Hospital  and  Health  Survey 


3.  That  large  hospitals  manufacture  nitrous  oxide  gas. 

4.  That  arrangements  be  made  to  purchase  oxygen  of  local  manufac- 
turers rather  than  of  jobbers.  This  will  necessitate  the  hospital  owning  its 
own  tanks  which  can  be  sent  to  manufacturers  for  refilling.  All  large  cities 
have  a  number  of  plants  manufacturing  oxygen  as  a  by-product.  Its  cost 
under  these  circumstances  should  be  50  per  cent,  less  than  prices  paid  job- 
bers. 

5.  That  rubber  gloves  be  not  issued  at  the  expense  of  the  hospital  to 
staff  members  for  use  on  private  cases,  or  to  non-staff  physicians. 

Visitors  and  Visiting  Hours 

Visiting  the  sick  should  be  limited  as  much  as  possible,  especially  in  open 
wards.  Hospitals  where  possible,  should  reduce  visiting  days  to  three  or 
four  days  per  week,  including  Sundays.  Two  of  these  days  could  have 
visiting  hours  for  wards  6 :00  to  7 :00  or  7 :00  to  8 :00  P.  M.,  and  the  remaining  two 
days  2:00  to  3:00  or  3:00  to  4:00  P.  M. 

Visitors  to  private  rooms  are  difficult  of  regulation.  They  should  be 
limited  if  possible  to  afternoons  between  2 :00  and  5 :00  P.  M. 

Xon-professional  visitors  in  the  operating  room  during  operations  should 
not  be  permitted.  The  practice  of  allowing  relatives  of  patients  to  witness 
operations  is  dangerous  and  susceptible  of  much  criticism.  It  should  not 
be  permitted. 


HYGIENE  OF  HOSPITAL  AND  PERSONNEL 

1.  Health  Tests — All  employes  handling  or  preparing  food  either  in 
storerooms,  kitchens,  pantries,  dining  rooms,  diet  kitchens,  etc.,  should 
have  a  complete  physical  examination,  including  a  Wassermann  examina- 
tion, before  being  accepted  for  appointment.  The  medical  examination 
and  tests  made  should  be  adequate  to  exclude  typhoid  carriers  from  this 
service. 

All  nurses  before  admission  to  the  training  school,  and  employes  before 
assuming  duties  of  their  positions  should  give  evidence  of  a  recent  vaccina- 
tion against  smallpox,  or  be  vaccinated. 

In  the  event  of  development  of  cases  of  diphtheria  among  hospital  per- 
sonnel, all  employes  and  nurses  should  have  the  Schick  Test  to  determine 
susceptibility.  The  making  of  a  Schick  Test  as  a  routine  procedure  prior  to 
employment  or  entry  to  the  training  school,  is  unnecessary.  It  should  not 
be  neglected,  however,  in  the  face  of  an  epidemic. 

The  authorities  of  the  hospital  should  provide  for  and  encourage  medical 
exmination  of  all  their  employes  annually. 

2.  Milk  Supply — Hospital  laboratories  should  install  apparatus  for 
testing  their  milk  supply  on  delivery  daily.  Determination  of  quantity  of 
butter  fat,  bacteria  content,  temperature  and  specific  gravity  will  permit 


Hospitals  and  Dispensaries  889 

checking  of  contract  which  would  provide  for  certain  minimum  standards. 
Hospital  milk  should  be  cooled  to  50  degrees  immediately  after  milking, 
delivered  at  the  hospital  before  reaching  60  degrees  and  contain  not  less  than 
4  per  cent,  of  butter  fat.  The  milk  contract  should  call  for  milk  for  drink- 
ing purposes  known  as  Class  "A"  grade.  Milk  should  be  delivered  to  hos- 
pital raw  and  provision  made  at  hospital  for  pasteurization  for  such  milk 
as  may  be  desired  pasteurized  prior  to  use.     (Note  G.) 

Note  F — Class  "A"  milk  in  Cleveland  is  raw  milk  from  tuberculin-tested  herds, 
scoring  90  per  cent,  or  better,  with  less  than  50,000  bacteria  content  per  c.c.  It  may  be 
necessary  in  some  instances  to  use  Class  "B"  pasteurized  milk,  which  conforms  with  Divi- 
sion of  Health  standards. 

3.  Water  Supply — The  hospital  laboratory  should  periodically  test  the 
water  supply.  If  storage  tanks  are  in  use,  tests  and  culture  should  be  made 
from  tanks  as  well  as  spigots. 

4.  Ventilation — During  the  winter  months,  hospitals  with  the  plenum 
system  should  give  rigid  attention  to  the  details  of  this  system  with  frequent 
examination  of  air  in  wards  and  exposure  of  culture  media.  Hospitals  using 
direct-indirect  methods  combined  with  heating,  during  winter,  should  make 
weekly  examinations  of  air  as  a  check  on  the  mechanical  operation  of  exhaust 
fans  and  the  mechanics  of  the  ventilating  system. 


890  Hospital  and  Health  Survey 

111.      Dispensaries 
DISPENSARIES  IN  CLEVELAND 

• 

As  outlined  in  the  section  entitled  "Some  Definitions,"  and  as  shown  in 
Figure  III.,  Part  II.,  there  are  two  classes  of  dispensaries  in  .Cleveland— - 
those  treating  the  sick  and  those  primarily  concerned  with  preventive  work, 
or 'the  clinical  and  the  public  health  dispensary,  as  the  two  types  may  be 
called.  In  Cleveland,  five  dispensaries  treating  the  sick  deal  with  general 
diseases;  one,  the  Babies'  Dispensary,  confines  its  work  to  children  under 
three  years.  There  are  also  a  number  of  industrial  dispensaries  supported 
by  business  establishments  for  the  treatment  of  accident  cases.  The  indus- 
trial dispensaries  are  dealt  with  in  Part  VII.  of  the  Survey  report,  and  are 
merely  mentioned  here.  The  public  health  dispensaries  are  dealt  with  in 
the  next  section  of  this  chapter. 

All  of  the  dispensaries  treating  the  sick  except  the  Babies'  Dispensary 
and  the  industrial  clinics  are  attached  to  hospitals,  and  are  usually  called 
the  out-patient  departments  of  those  hospitals.  All  of  the  public  health 
dispensaries,  on  the  other  hand,  are  distinct  from  hospitals,  with  the  excep- 
tion of  a  few  of  the  prenatal  clinics. 

The  six  dispensaries  treating  the  sick  are  as  follows: 

Dispensaries  Dispensary  Visits,  1919 

Lakeside  Hospital — Out-patient  Department 59,89 1 

St.  Vincent's  Charity  Hospital — Out-patient  Department ..     21,863 

Mount  Sinai  Hospital — Out-patient  Department.- 19,324 

Babies'  Dispensary  and  Hospital 14,977 

St.  Luke's  Hospital — Out-patient  Department 13,313 

Huron  Road  Hospital — Out-patient  Department.- 5,864 

It  is  probable  that  the  number  of  different  individuals  treated  was  about 
30,000  in  1919. 

From  the  above  table  it  will  be  found  that  the  dispensaries  of  Cleveland 
are  comparatively  few  in  number  and  small  in  size  as  compared  with  those  of 
other  leading  cities.  In  the  section  on  "Policies  and  Needs,"  such  compari- 
sons willjbe  made.  In  this  section  the  general  work  of  the  dispensaries  is 
reviewed. 

Location  of  Dispensaries 

The  six  out-patient  dispensaries  are  very  unevenly  distributed — Lakeside 
is  on  the  lake  at  East  Twelfth  Street;  Charity  is  one  mile  inland  at  Twenty- 
second  Street;  and  Mount  Sinai  about  one  mile  and  a  half  inland  at  105th 
Street.  These  three  dispensaries  treat  all  kinds  of  diseases.  Huron  Road 
Dispensary,  located  in  the  center  of  the  city,  does  very  little  except  surgical 


Hospitals  and  Dispensaries 


891 


m  i  -i  C  K")  ui 


Fig.  III. 


NOTE: — The  height  of  the\black  rectangles  represents  the  percentage  of  dispensary  patients  living  in 
the  district  and  attending  the  dispensary  designated  by  the  letter  above. 


892  Hospital  and  Health  Survey 

emergency  work;  the  same  is  true  of  St.  Luke's,  which  is  in  the  middle  of  an 
industrial  district.  The  Babies'  Dispensary,  not  far  from  Charity  Hospital, 
confines  itself  to  sick  babies  up  to  the  age  of  three  years.*     ' 

A  study  of  locations  shows  that  the  dispensaries  are  not  so  located  as  to 
interfere  with  one  another,  but  it  is  obvious  that  the  west  and  south  sides  of 
the  city  are  entirely  without  provision.  The  range  from  which  patients  come 
to  the  dispensaries  varies  considerably  as  shown  by  Fig.  III.  In  Cleveland,  as 
elsewhere,  it  is  found  that  a  dispensary  with  medical  teaching  draws  from  a 
relatively  wider  area,  since  consultation  cases  are  sent  to  its  staff  for  special 
study  and  since  the  reputation  of  its  staff  draws  patients.  In  general  the 
range  of  a  dispensary  varies  somewhat  in  proportion  to  its  reputation. 
People  will  go  long  distances  to  secure  expert  medical  care  of  which  they 
feel  themselves  to  be  greatly  in  need,  but  convenience  of  location  and  near- 
ness of  a  dispensary  are  of  great  assistance  in  bringing  people  in  the  early 
stages  of  disease  under  care  and  in  attaining  easy  supervision  of  treatment. 

Classes  of  Disease  Treated 

Tuberculosis  is  not  cared  for  in  these  dispensaries  except  in  so  far  as  diag- 
noses are  made  when  patients  come  into  the  dispensary  with  other  com- 
plaints, but  the  supervision  and  control  of  cases  of  tuberculosis  are  carried 
on  by  the  Health  Centers  and  the  special  sanatoria  for  this  disease.  The 
common  "contagious"  diseases  are  also  excluded  from  dispensaries. 

Organization  and  Executive  Control 

The  management  of  a  dispensary  of  any  size,  such  as  those  at  Lakeside 
and  Mount  Sinai,  involves  the  handling  of  a  considerable  number  of  patients 
and  a  number  of  physicians,  nurses,  social  workers,  and  other  assistants,  and 
needs  skilled  and  executive  direction.  Rarely,  however,  has  there  been  pro- 
vided by  the  hospital  any  officer  responsibly  charged  with  full  control  of  the 
dispensary  and  expected  to  give  to  it  his  main  attention.  At  Lakeside  and 
Mount  Sinai,  an  assistant  superintendent  of  the  hospital  is  director  of  the  dis- 
pensary, but  at  Lakeside  until  recently  the  actual  conduct  of  the  dispensary 
fell  entirely  upon  the  head  of  the  social  service  department.  At  the  smaller 
dispensaries — at  Huron  Road  Hospital  and  at  St.  Luke's  Hospital,  and  also  at 
Charity  Hospital,  there  have  been  no  executive  directors.  The  hospital 
superintendent  is  responsible  for  the  dispensary  as  well  as  for  other  depart- 
ments of  the  hospital,  but  no  official  has  been  assigned  to  take  charge  of  the 
dispensary. 

Only  at  the  Babies'  Dispensary  has  there  been  definite  and  continued 
executive  direction  and  carefully  worked  out  organization,  under  the  pro- 
fessor of  pediatrics  at  the  University,  with  a  salaried  nurse  devoting  her  full 
time  to  the  detailed  administration.  This  organization  has  indeed  devoted 
too  much  attention  to  its  own  executive  detail  and  administrative  system, 

*A  small  number  of  orthopedic  cases  receiving  special  treatment  are  accepted  up  to  14  years  of  age 
at  the  Babies'  Dispensary. 


Hospitals  and  Dispensaries  893 

but  furnishes  on  the  whole  an  example  of  the  value  of  a  well-thought-out 
and  well-worked-out  plan  of  dispensary  administration  under  full-time, 
responsible  executive  direction. 

Buildings 

The  Babies'  Dispensary  is  especially  well  designed  for  its  purpose.  The 
other  dispensaries  are  all  hampered  for  want  of  room  or  from  old  dark  build- 
ings. St.  Luke's  and  Charity  function  in  basements;  Huron  Road  in  a  rather 
forlorn  annex;  Mount  Sinai  in  a  small  double  house;  and  Lakeside  in  poorly- 
arranged,  inconvenient  rooms.  All  of  the  institutions  except  Charity  are 
planning  new  buildings,  and  Lakeside  is  planning  certain  modifications  of  the 
present  plant  that  will  make  it  much  more  suitable  during  the  remainder  of 
the  time  the  building  is  in  use.  The  unsuitable  or  inconvenient  character  of 
the  plants  is  typical  of  the  lack  of  attention  paid  to  dispensary  work  in  the 
past,  while  the  increasing  interest  in  this  form  of  service  is  reflected  in  the 
projected  developments. 

Patients 

As  shown  on  the  map  (Fig.  III.),  the  existing  dispensaries  draw  their  pa- 
tients largely  from  the  central  congested  areas  of  the  city.  Sufficient  num- 
bers come  from  a  distance  to  show  that  when  the  work  and  existing  value  of 
dispensaries  is  known,  distance  is  not  an  insuperable,  obstacle.  It  would  be 
interesting  and  important  to  ascertain  how  far  the  distribution  of  dispensary 
patients  by  districts  agrees  with  the  economic  condition  of  the  population  in 
each  section.  Obviously,  the  dispensary  draws  primarily  from  the  poorer 
elements.  There  are  considerable  districts  in  the  west  and  south  sides 
which  appear  to  contain  a  large  number  of  people  who  are  financially  as  much 
in  need  of  medical  charity  as  those  who  are  near  the  existing  dispensaries. 
Some  light  is  thrown  on  this  point  by  the  study  of  nationalities.  Thirty- 
three  nationalities  were  found  registered  among  records  studied  in  the  six 
dispensaries.  The  proportion  of  foreign -born  found  in  the  more  recent  of 
these  records  of  races  is  smaller  than  the  proportion  which  these  races  bear 
to  the  total  population  of  Cleveland.  Knowledge  of  dispensaries  and  willing- 
ness to  go  to  a  strange  institution  penetrate  only  slowly  among  many  groups 
of  immigrants.  At  Lakeside  Dispensary,  American-born  patients  consti- 
tuted over  one-half  of  the  total;  Charity  draws  largely  from  Italians  and 
Negroes;  Mount  Sinai  shows  over  half  of  its  attendance,  Jewish;  Babies' 
Dispensary  shows  24  per  cent.  American-born  parents,  18  per  cent.  Slavic, 
16  per  cent.  Jewish,  14  per  cent,  colored,  and  many  other  nationalities  rep- 
resented in  small  percentages.  Very  little  has  been  done  at  any  of  the  dis- 
pensaries to  provide  interpretation  for  patients  not  speaking  English.  There 
is  much  complaint  from  outside  charitable  agencies  that  adult  patients  not. 
speaking  English  find  it  difficult  to  make  themselves  understood,  or  to 
understand  what  the  doctor  finds  to  be  the  matter  or  what  he  wants  them  to 
do. 


894  Hospital  and  Health  Survey 


Fees  and  Finances 

It  is  becoming  the  general  policy  of  dispensaries  throughout  the  country 
to  charge  admission  fees  at  each  visit  of  a  patient,  the  fee  usually  being  of 
nominal  amount  (except  in  "pay  clinics")  and  being  remitted  in  whole  or 
in  part  where  the  patient  is  not  able  to  pay.  In  Cleveland,  only  one  of  the 
five  general  dispensaries,  Lakeside,  has  adopted  a  general  admission  fee  in 
its  daytime  clinics.  Mount  Sinai  Dispensary  charges  ten  cents  for  the 
first  admission  but  not  thereafter,  and  Charity  makes  a  nominal  charge 
when  a  person  loses  his  admission  card.  All  make  charges  for  medicines  at 
prices  more  or  less  corresponding  to  cost,  and  also  usually  charge  for  special 
treatment  or  appliances. 

In  the  evening  clinics  which  are  designed  for  persons  who  are  at  work 
in  the  daytime  and  generally  aim  to  be  quite  or  nearly  self-supporting,  fifty 
cents  a  visit  is  charged  by  Mount  Sinai,  Charity,  and  Lakeside — the  three 
dispensaries  which  maintain  such  clinics.  Babies'  Dispensary  has  a  grade 
system — the  highest  class  pays  fifty  cents  and  the  lowest  grade  nothing  for 
admission. 

The  charging  and  collection  of  fees  and  the  designation  of  what  these 
fees  should  be  and  when  and  why  they  should  be  remitted,  require  an  adequate 
admission  system  for  a  dispensary.  The  present  inadequate  organization  of 
most  of  the  institutions  would  make  it  difficult  to  administer  satisfactorily  an 
admission  fee  system.  It  is  of  course  essential  that  if  admission  fees  are 
routinely  charged,  there  be  a  system  for  receiving  and  accounting  accu- 
rately for  monies,  as  well  as  for  deciding  what  fees  should  be  paid  by  patients 
or  be  remitted.  Having  such  a  system  in  a  dispensary  is  always  stimulating 
to  better  administration  and  also  serves  to  provide  the  funds  for  it.  An  im- 
portant by-product,  moreover,  is  the  greater  attention  given  to  the  economic 
and  social  condition  of  patients,  promoting  more  careful  attention  to  the 
social  as  well  as  the  medical  needs  of  those  admitted,  and  protecting  the 
medical  profession  better  against  those  who  could  properly  pay  for  the  ser- 
vices of  a  private  physician. 

The  exact  cost  of  dispensary  service  in  Cleveland  is  not  ascertainable 
because  no  one  of  the  out-patient  departments  of  the  hospitals  fully  sep- 
arates its  expenses  from  those  of  the  hospital.  Immediate  expenses  are 
usually  charged  to  the  dispensary,  but  the  overhead — heating,  lighting,  super- 
vision, and  other  general  expenses — are  not  usually  figured  in.  It  is  probable 
that  the  average  cost  per  visit  does  not  exceed  fifty  cents  with  the  exception 
of  the  Babies'  Dispensary,  which  is  independent  of  a  hospital.  The  five  out- 
patient departments  of  the  hospitals,  with  about  115,000  visits,  probably 
cost  altogether  about  $60,000  a  year.  Really  adequate  administration  of  the 
dispensaries  as  hereafter  recommended  would  cost  more,  but  the  difference 
would  be  met  or  more  than  met  if  adequate  admission  fees  were  charged. 
Failure  to  have  proper  cost  accounting  is  a  serious  limitation  on  dispensary 
service.     What  seems  cheap,  is  held  cheaply. 


Hospitals  and  Dispensaries  895 

Medical  Work  or  Dispensaries 

Physicians  work  in  the  daytime  clinics  of  the  dispensaries  without  finan- 
cial remuneration,  except  in  a  few  instances  of  physicians  doing  special  work 
at  Lakeside  and  at  the  Babies'  Dispensary.  These  two  dispensaries  are 
teaching  clinics  for  Western  Reserve  University,  members  of  the  staff  being 
also  members  of  the  staff  of  the  medical  school.  In  the  evening  pay  clinics, 
all  the  physicians  receive  either  a  regular  salary  or  an  amount  dependent  on 
the  fees  received  from  patients.  A  large  part  of  the  dispensary  work  in 
Cleveland  is  connected  with  the  teaching  of  medical  students,  all  of  the  staff 
at  Lakeside  and  at  Babies'  Dispensary,  and  part  of  the  staff  of  Charity  and 
of  Huron  Road,  being  connected  with  Western  Reserve  University  Medical 
School. 

The  dispensary  staffs  are  only  in  a  few  instances  organized  satisfactorily 
in  relation  to  the  staffs  of  the  hospital  with  which  the  dispensary  is  con- 
nected. (See  section  on  "Organization  for  Service.")  The  practice  of 
making  all  appointments  annually  has  been  taken  advantage  of  only  at 
Mount  Sinai.  The  Babies'  Dispensary  is  the  only  one  that  has  an  accurate 
and  complete  enough  system  of  record  keeping  to  afford  a  basis  for  clinical 
research.  Most  of  the  opportunity  for  the  student  is  lost  because  of  inade- 
quate records,  and  much  duplication  of  work  among  dispensaries  and  within 
the  same  dispensary  is  necessitated  for  the  same  reason. 

Opportunities  for  consultation  among  physicians  representing  different 
specialties  is  an  important  element  in  good  dispensary  work,  but  this  oppor- 
tunity is  relatively  small  in  the  Cleveland  dispensaries  owing  to  loose  organ- 
ization and  to  very  lax  systems  of  referring  and  transferring  patients  be- 
tween dispensaries  or  clinics.  The  making  of  efficiency  tests  of  the  medical 
work  and  the  accumulation  of  facts  on  which  to  base  judgment  concerning 
administrative  procedures  has  yet  to  be  undertaken. 

Records 

All  of  the  five  general  dispensaries  excepting  Charity  have  a  central 
filing  system — all  records  concerning  each  patient  being  filed  together.  At 
Charity,  the  filing  of  the  records  of  each  particular  clinic  separately  repre- 
sents a  serious  drawback  since  the  work  of  the  different  specialists  upon  a 
case  cannot  readily  be  assembled  and  the  needs  of  the  patient  studied  as  a 
whole.  Card  record  forms  for  the  medical  work  are  in  general  use,  differing 
widely  in  detail.  Conference  and  comparison  would  lead  to  improvement 
and  standardization.  Mount  Sinai  has  a  plan  for  a  summary  sheet  for 
diagnosis  and  laboratory  tests,  an  experiment  which  is  worth  pursuing. 

Social  Service 

The  too  considerable  part  played  by  under-staffed  social  service  depart- 
ments in  the  administration  of  several  of  the  dispensaries  is  described  in 
detail  in  the  section  on  "Social  Service".  It  may  be  mentioned  here  that 
in  relation  to  cooperation  with  charitable  agencies,  the  social  service  de- 


896  Hospital  and  Health  Survey 

partments  have  usually  made  an  effort  to  define  their  attitude  toward  the 
social  agencies,  particularly  in  relation  to  the  need  of  patients  for  material 
relief.  All  of  the  social  service  departments  are  avowedly  opposed  to  the 
giving  of  material  relief,  regarding  this  as  the  duty  of  a  "family  agency"  or 
relief  society.  In  general  an  exception  is  made  of  certain  medical  needs 
which  the  social  service  departments  regard  as  adequate  reason  for  giving 
financial  aid.  Thus  at  Mount  Sinai,  it  is  felt  that  a  patient's  inability  to 
pay  for  glasses  or  for  dental  work  is  an  indication  that  there  are  other  more 
general  financial  needs  and  the  case  is  transferred,  by  the  social  service 
department,  to  general  charitable  or  relief  agency.  Lakeside  Social  Serv- 
ice Department  will  give  money  to  patients  for  carfare  and  occasionally 
will  make  small  loans.  A  very  small  fund  is  in  the  possession  of  this  depart- 
ment for  such  purposes.  The  Babies'  Dispensary  provides  milk  at  less  than 
cost  or  free,  if  necessary.  This  is  provided  for  babies  up  to  the  age  of  fifteen 
months;  after  that  if  the  baby  is  ill,  it  will  be  continued  up  to  eighteen  months, 
but  never  later.  This  is  also  done  at  the  Health  Centers.  The  total  deficit 
for  the  year  1919  was  $18,000,  of  which  the  city  pays  $6,000  and  the  Babies' 
Dispensary  $12,000.  With  these  exceptions  the  social  service  departments 
do  not  give  material  relief,  but  transfer  to  charitable  agencies  all  cases  in 
which  such  needs  appear  evident  or  probable.  Thus  a  pretty  clear  division 
of  function  between  the  social  service  department  and  the  non-medical 
agencies  has  been  worked  out. 

On  the  other  hand,  there  has  not  been  a  satisfactory  understanding  be- 
tween the  dispensaries  and  the  charitable  agencies  with  reference  to  the 
examination  of  patients  not  acutely  ill,  but  concerning  whom  a  charitable 
society  needs  to  secure  facts  as  to  physical  condition,  working  ability,  and 
the  general  health  needs  of  the  family.  In  some  instances,  notably  at  Lake- 
side, it  has  been  difficult  for  charitable  societies  to  secure  examination  of 
these  cases,  who  often  not  being  sick,  do  not  interest  physicians  coming  to 
the  dispensaries  primarily  to  see  and  treat  illness.  It  has  also  been  difficult, 
at  Lakeside  almost  impossible,  for  charitable  societies  and  agencies,  to  secure 
information  regarding  the  diseases  or  defects  found  in  patients  in  whom 
they  are  interested.  The  families  known  to  charitable  societies  and  receiv- 
ing relief  from  them,  can  obviously  not  afford  to  pay  for  medical  care,  and 
it  is  particularly  for  such  families  that  dispensaries  should  serve  as  family 
physicians.  This  means  providing  health  examinations  and  advice  concern- 
ing occupation,  nutrition,  etc.,  as  well  as  diagnosis  and  treatment  during 
illness.  The  dispensaries  have  given  only  a  very  limited  degree  of  service 
in  this  connection,  although  a  real  beginning  has  been  made  at  such  places 
as  the  Babies'  Dispensary  and  Mount  Sinai.  An  important  field  for  larger 
service  lies  here. 

Reports  and  Tests  of  Dispensary  Service 

The  annual  reports  of  the  dispensaries  are  most  inadequate.  The  dis- 
pensaries probably  serve  altogether,  in  a  year,  as  many  as  30,000  persons — 
hospital  beds,  50,000  to  60,000,  or  twice  as  many.  Yet  the  attention  devoted 
to  reports  of  hospital  work  is  not  twice  as  much  as  that  given  to  dispensary 
reports,  but  ten  times  as  much  or  some  such  ratio.     Even  the  number  of 


Hospitals  and  Dispensaries  897 

patients  served  or  treatments  given  in  each  of  the  several  clinics — medical, 
surgical,  etc.,  were  not  obtainable  from  the  dispensary  reports,  (except  from 
one  institution)  and  had  to  be  specially  secured  for  the  Survey.  The  authori- 
ties of  the  institutions  have  not  provided  themselves  with  the  elementary 
data  with  which  to  judge  even  the  scope  and  amount  of  service  rendered, 
much  less  its  quality.  The  collection  of  routine  statistics  of  the  work  of 
each  clinic  is  a  matter  neither  difficult  nor  costly. 

Deficiencies  in  Certain  Branches 

Like  the  hospitals,  the  dispensaries  are  undeveloped  in  certain  important 
specialties  in  which  the  public  needs  service.  Clinics  for  children  (over  the 
age  of  three)  are  the  most  notable  example.  The  children's  clinics  at  Lake- 
side and  Mount  Sinai  are  very  small;  there  are  none  at  Charity  Hospital, 
Huron  Road,  or  St.  Luke's.  The  age  limit  set  by  the  Babies'  Dispensary 
has  been  an  unfortunate  restriction.  It  has  served  to  limit  the  development 
of  clinics  for  babies  elsewhere,  and  has  indirectly  tended  to  diminish  the 
chance  of  adequate  clinics  for  older  children.  Moreover,  no  one  clinic  for 
sick  babies  can  meet  the  need  for  a  city  as  large  as  Cleveland.  All  sick 
babies  needing  dispensary  care  are  expected  to  come  to  one  spot,  the  Babies' 
Dispensary,  and  even  when  there  they  are  not  treated  unless  the  nurse  at 
the  admission  desk  agrees  with  the  mother,  or  with  the  visiting  nurse  who 
referred  the  mother,  that  the  baby  is  too  ill  to  be  at  a  Babies'  Prophylactic 
Station  and  that  the  family  is  too  poor  to  pay  a  private  physician.  A  study 
by  the  Survey  showed  that  somewhat  more  than  half  of  a  group  of  cases 
recently  applying  at  the  Babies'  Dispensary  were  referred  elsewhere.  It  is 
to  be  strongly  recommended  that:  (1)  Babies'  Dispensary  accept  children 
up  to  14  years.  (2)  Pediatric  Clinics  treating  children  up  to  this  age  be 
developed  at  all  present  and  future  dispensaries. 

Clinic  service  for  cases  of  heart  disease  is  an  undeveloped  field  in  Cleve- 
land. Mount  Sinai  appears  to  have  recognized  the  problem  and  to  have 
begun  efforts  to  get  cardiac  cases  under  care,  at  Rainbow  Hospital.  It  is 
highly  desirable  that  cardiac  clinics  be  developed  as  parts  of  the  general 
dispensaries  which  exist  or  are  to  be  established  at  City  Hospital,  Lakeside, 
Mount  Sinai  and  the  proposed  central  downtown  dispensary. 


Relation  of  Dispensaries  and  Hospitals 

The  usefulness  of  the  out-patient  department  as  a  means  of  increasing 
the  efficiency  of  the  hospital  has  been  but  slightly  recognized  in  Cleveland. 
The  dispensary  should  be  the  link  whereby  most  of  the  hospitals'  contacts 
with  the  community  are  made.  Thus  the  admission  of  ward  patients  should 
be  largely  through  the  dispensary,  though  of  course  emergency  and  some 
other  cases  will  enter  otherwise.  The  medical  study  given  in  the  dispensary 
to  the  patient  should  be  the  beginning  of  the  hospital's  work  with  him  and 
not,  as  now,  be  usually  wasted  because  the  medical  organization  and  the 
records  of  the  out-patient  department  are  not  correlated  with  those  of  the 
hospital. 


Hospital  and  Health  Survey 


Fig.  IV. 
Inter-relation  Between  Hospital  and  Dispensary. 


Hospitals  and  Dispensaries  899 

Of  equal  if  not  greater  importance,  is  the  function  of  the  dispensary  in 
connection  with  the  discharged  patient.  This  subject  is  studied  in  detail 
in  the  sections  on  convalescence. 

Clinic  Management 

The  time  of  doctors,  given  freely  to  service  in  clinics,  is  much  too  largely 
spent  in  non-medical  routine — calling  in  patients,  attending  to  records,  etc. 
Paid  and  trained  clinical  assistants  is  necessary  if  the  doctor's  time  in  the 
clinic  is  to  be  of  maximum  value  to  himself  and  to  the  patient.  The  details 
of  efficient  clinic  management  have  been  worked  out  in  a  number  of  dispen- 
saries in  other  cities. 

Relations  to  the  Medical  Profession 

There  has  been  for  some  years  an  apparent  feeling  on  the  part  of  some 
members  of  the  medical  profassion  that  dispensaries  interfere  with  private 
medical  practice  because  they  accept  patients  who  could  afford  to  pay  a 
physician.  Much  of  this  feeling  has  been  due  to  misapprehension  of  the 
facts;  some  has  been  due  to  the  failure  on  the  part  of  the  hospitals  to  deal 
with  the  medical  profession  on  even  and  open  terms.  The  Survey  has  found 
no  evidence  that  cases  who  are  able  to  pay  a  private  physician  have  been 
accepted  by  the  dispensaries  except  occasionally,  by  mistake  or  honest  mis- 
judgment,  and  the  proportion  of  such  mistakes  appears  no  larger  than  studies 
in  New  York  and  Boston  have  shown  to  be  practically  inevitable.  The  pro- 
portion of  dispensary  applicants  who  are  able  to  pay  private  rates  for  the 
medical  care  which  they  need  is  believed  not  to  be  larger  than  three  per  cent, 
and  as  the  records  of  the  Babies'  Dispensary,  of  Lakeside,  and  of  other  insti- 
tutions show,  a  number  of  such  applicants  are  refused  treatment.  The  prin- 
ciples which  it  is  believed  should  govern  the  admission  of  patients  to  dis- 
pensaries are  stated  in  the  section  on  "Policies  and  Needs." 

It  has  been  unfortunate  that  this  vital  matter  of  relationship  between 
the  dispensary  and  the  physician  should  not  have  been  made  the  subject  of 
systematic  cooperation,  conference  and  study  by  representatives  of  both 
sides.  Had,  for  instance,  a  committee  of  the  Hospital  Council  met  with  a 
committee  of  the  Cleveland  Academy  of  Medicine  a  number  of  times  during 
the  past  five  years,  there  would  probably  never  have  developed  any  atti- 
tude of  disagreement.  In  the  section  on  "Policies  and  Needs"  a  recommen- 
dation is  made  with  the  aim  of  bringing  about  such  cooperative  functioning. 
It  is  of  vital  importance  to  remember  that  the  dispensary  (also  the  hospital) 
is  essentially  a  cooperative  enterprise  of  the  medical  profession  and  the  trus- 
tees and  administrators,  undertaken  for  the  purpose  of  community  service. 
The  adequate  development  of  dispensaries  in  Cleveland  will  offer  to  the  rank 
and  file  of  the  medical  profession  opportunities  of  which  it  is  now  largely 
deprived — for  consultation  with  specialists  and  for  aid  from  laboratories 
and  other  facilities  in  diagnosis  and  treatment.     Physicians  may  be  sure  that 


900  Hospital,  and  Health  Survey 

whatever  assists  the  public  to  give  more  attention  to  bodily  health  and  to 
understand  and  utilize  the  most  advanced  resources  for  medical  care,  will 
also  stimulate  the  use  of  that  primary  and  best  loved  resource,  the  family 
physician. 


Hospitals  and  Dispensaries  901 


THE  PUBLIC  HEALTH  DISPENSARIES 

As  previously  pointed  out,  the  public  health  dispensaries  differ  from  those 
just  described  in  that  they  lay  emphasis  on  preventive  work  rather  than  on 
diagnosis  and  treatment  of  sickness.  They  also  differ  in  that  each  public 
health  dispensary  limits  itself  to  a  definite  area,  receiving  patients  only  from 
this  district.  Generally  speaking,  the  offer  of  a  preventive  and  educational 
service  will  draw  persons  from  a  much  smaller  area  than  in  the  case  of  a 
clinic  treating  sickness.  The  effective  range  of  an  infant  welfare  clinic  is 
quite  smill;  that  is.  the  area  from  which  it  will  draw  many  cases  L  limited 
to  a  comparatively  small  region  around  the  dispensary.  The  same  is  true 
of  the  prenatal  clinic,  while  the  tuberculosis  clinic  has  a  somewhat  wider 
range.  In  practice  the  district  which  a  public  health  dispensary  does  serve 
depends  largely  upon  the  extent  to  which  it  is  advertised  or  the  degree  to 
which  nurses  attached  to  the  dispensary  go  into  homes  and  interest  persons 
to  come  to  the  clinic.  These  efforts,  however,  are  at  a  disadvantage  if  an 
attempt  is  made  to  bring  many  persons  from  considerable  distances. 

The  public  health  dispensary  has  a  militant  purpose.  It  aims  to  combat 
a  definite  disease  like  tuberculosis  or  a  group  of  diseases  such  as  cause  infant 
mortality.  It  should  make  no  restriction  in  receiving  patients  because  of 
financial  status.  Properly  conducted,  a  public  health  dispensary  should  in 
no  way  interfere  with  the  work  of  private  physicians,  but  tends  to  send 
patients  to  them  since  disease  or  difficulties  are  discovered  which  dispensaries 
will  not  treat  and  for  which  patients  will  be  advised  to  seek  treatment.  The 
aim  of  a  public  health  dispensary  is,  or  ought  to  be,  the  reaching  of  all  of  the 
cases  within  a  certain  district  needing  its  care.  It  must  measure  its  work 
on  a  population  basis  and  see  how  far  it  is  able  to  reach  100  per  cent,  of  the 
cases  of  actual  or  probable  tuberculosis  in  its  district,  or  all  the  babies  or 
expectant  mothers.  This  in  practice  would  require  that  a  public  health 
dispensary,  with  a  certain  staff,  must  serve  only  so  large  a  district  as  it  can 
effectively  reach.  The  time  has  not  yet  come  when  a  general  statement 
can  be  made  as  to  the  area  which  a  given  type  of  public  health  dispensary 
can  cover,  and  this  must  be  the  subject  of  further  study  in  Cleveland  and 
elsewhere. 

Reference  to  Table  I.  shows  that  twenty-two  different  sites  are  utilized 
for  public  health  dispensaries  or  clinics  with  a  public  health  purpose,  and 
that  the  purposes  served  include  four  types  of  work:  tuberculosis,  infant 
welfare,  prenatal  care,  and  dental  service.  It  should  be  added  that  the 
three  clinics  treating  the  venereal  diseases  (at  Lakeside,  Mount  Sinai  and 
Charity  Hospitals)  fall  on  the  border  line  between  the  public  health  dispen- 
sary and  the  dispensary  treating  the  sick.  They  have  or  should  have  the 
militant  purpose  of  the  public  health  dispensary,  but  they  are  largely  con- 
cerned with  the  diagnosis  and  treatment  of  definite  disease.  Since  Part  V. 
of  the  Survey  report  is  devoted  to  venereal  diseases  only  this  mention  is 
made  here. 

Further  reference  to  Table  I.  indicates  that  the  first  two  of  the  four 
services,  tuberculosis  and  infant  welfare,  are  under  the  charge  of  the  Division 


902  Hospital  and  Health  Survey 


of  Health,  while  the  other  two,  prenatal  and  dental  service,  are  under  private 
agencies.  The  Survey  reports  on  Child  Hygiene  (Part  III.)  and  on  Nursing 
(Part  IX.)  have  given  considerable  attention  to  prenatal  as  well  as  to  the 
other  public  health  services  which  involve  the  nurses'  work  in  the  home  as 
well  as  in  the  clinics,  and  the  report  on  Tuberculosis  (Part  IV.)  has  covered 
that  field.     Certain  administrative  aspects  may  properly  be  discussed  here 


Prenatal  Clinics 

In  prenatal  service  the  function  of  the  clinic  is  essentially  diagnosis.  The 
examining  physician  should,  so  far  as  possible,  be  able  to  decide  what  special 
care,  if  any,  each  expectant  mother  requires  during  pregnancy  and  at  delivery, 
and  to  advise  her  accordingly.  The  diagnostic  and  administrative  work  of 
the  clinic  are  of  relatively  limited  value  without  the  home  work  of  the  nurse. 
The  prenatal  clinics  also  play  a  certain  part  in  medical  and  nursing  education. 
It  should  be  apparent,  however,  that  the  amount  of  clinical  service  or  the 
number  of  obstetrical  cases,  needed  for  such  purposes  of  education,  is  only 
a  small  fraction  of  the  amount  of  prenatal  service  needed  for  the  community 
as  a  whole.  In  1919  there  were  19,123  registered  births  in  Cleveland,  and 
of  these  1,251  were  delivered  in  their  homes  by  out-patient  teaching  services 
connected  with  the  prenatal  clinics  of  Maternity  Hospital.  This  is  6^  per 
cent,  of  the  total.  It  is  certainly  true  that  not  over  10  per  cent,  of  the  obstet- 
rical cases  of  Cleveland  are  required,  Or  could  even  be  directly  utilized,  for 
teaching  purposes  in  connection  with  prenatal  clinics.  Practically  every 
expectant  mother  would  benefit  by  such  service  as  is  rendered  at  a  well 
managed  prenatal  clinic.  The  need  of  prenatal  care  is  far  broader  than  the 
need  for  "educational  material."  The  two  purposes  are  not  at  all  inconsis- 
tent.    The  one  fits  into  the  other. 

The  point  is  of  practical  importance  because  of  the  failure  of  those  respon- 
sible for  the  University  teaching  of  obstetrics  and  for  the  maintenance  of 
the  prenatal  clinics  connected  therewith,  to  recognize  the  community  need 
as  broader  than  their  own  special  interest.  Four  different  agencies  main- 
tain eight  prenatal  clinics.  There  is  room  for  many  more  than  eight  prenatal 
clinics  and  for  more  than  four  agencies,  provided  all  were  working  as  part  of 
an  agreed  general  program.  At  present  the  University  agency  appears  to 
take  the  attitude  of  urging  the  cessation  of  the  activities  of  such  prenatal 
clinics  as  those  of  Mount  Sinai  and  the  University  District.  The  feeling 
produced  on  the  other  side  is  what  may  be  expected.  The  effectiveness  as 
well  as  the  extent  of  the  work  is  substantially  diminished  by  such  a  situation. 
As  a  reductio  ad  absurdum  we  find  two  prenatal  clinics,  next  door  to  one 
another,  at  2509  and  2511  East  Thirty-fifth  Street,  one  conducted  by  Ma- 
ternity Hospital,  the  other  by  the  University  District,  for  the  training  of  its 
students. 

The  recommendations  made  by  the  Survey  in  the  reports  on  Child  Hygiene 
(Part  III.)  and  Nursing  (Part  IX.)  will  remedy  this  condition  if  put  into  effect. 
It  may  be  added  here,  as  one  detail,  that  there  is  no  justification  for  two 


Hospitals  and  Dispensaries  903 

clinics  side  by  side  on  Thirty -fifth  Street.  Although  the  University  District 
prenatal  clinic  is  actually  under  the  auspices  of  the  Division  of  Health,  it,  as 
well  as  the  Maternity  Hospital  prenatal  clinic,  is  used  as  a  teaching  field 
by  the  University,  and  it  is  largely  the  responsibility  of  the  University  to 
see  that  its  agents  and  officers  dealing  respectively  with  medical  and  with 
nursing  education,  work  in  harmony.  The  two  clinics  should  be  combined. 
It  is  a  matter  of  indifference  which  plant  is  retained  and  which  given  up. 
The  University  should,  as  now,  appoint  the  medical  and  nursing  heads  of 
the  service;  the  internal  administration  of  the  clinic,  for  reasons  of  economy 
and  convenience,  should  continue  under  Maternity  Hospital;  the  nursing 
teaching  should  be  part  of  the  University  District  plan  and  be  coordinated 
with  the  community  plan  for  prenatal  and  obstetrical  nursing  service  pro- 
posed by  the  Survey.     (See  Part  III.) 

It  is  generally  helpful  for  a  hospital  which  has  a  considerable  maternity 
service  in  its  wards,  to  maintain  a  prenatal  clinic  (which  should  be  used  also 
for  the  supervision  of  post-partum  conditions  and  be  administered  as  part  of 
the  general  dispensary  attached  to  the  hospital) .  Such  hospital  clinics  should, 
however,  work  as  cooperative  parts  of  the  city-wide  plan  for  maternity  care. 
There  is  need  for  many  more  prenatal  clinics,  however,  than  are  or  can  be 
connected  with  hospitals.  Wherever  possible  the  prenatal  clinics  should  be 
in  the  same  buildings  as  the  Health  Centers  of  the  Division  of  Health.  By 
the  bringing  together  of  a  variety  of  different  health  activities  within  one 
building,  each  service  tends  to  strengthen  the  others  by  increasing  the  con- 
tact of  the  neighborhood  with  the  Center,  its  purposes  and  personnel;  and 
to  correlate  many  details  of  work  by  the  medical,  nursing  and  clerical  staffs. 
Such  combinations  also  bring  administrative  economies  in  management  and 
save  such  present  wastes  as  renting  rooms  for  prenatal  clinics  which  are  used 
only  i  few  hours  each  week.  In  advance  of  the  assumption  by  the  city  of 
prenatal  work  as  a  regular  servi  'e  in  its  Health  Centers,  cooperation  between 
the  city  and  the  private  agencies  may  usefully  proceed  in  this  manner. 


Dental  Clinics 

Dental  service  as  a  branch  of  public  health  dispensaries  is  a  recognized 
activity  in  which  Cleveland  is  singularly  deficient. 

The  three  mouth  hygiene  dispensaries  operated  by  the  Cleveland  Mouth 
Hygiene  Association  at  three  of  the  health  centers  are  operated  for  fifty  weeks 
of  the  year,  five  days  a  week,  and  three  hours  at  each  session.  Each  unit  in- 
cludes a  dentist  and  an  assistant.  The  cost  of  these  is  met  from  the  Com- 
munity Fund  as  a  part  of  the  budget  presented  by  the  Welfare  Federation. 

These  three  Mouth  Hygiene  dispensaries,  operated  five  half  days  pee 
week,  are  the  only  available  and  acceptable  service  (except  the  private  dental 
practitioner)  for  thirty  to  thirty-five  thousand  parochial  school  children.  It 
is  estimated  that  fifteen  Mouth  Hygiene  Units  operated  eleven  half  days  per 
week  would  serve  this  group  of  children  quite  well;  i.  e.,  would  provide  the 
prophylactic  service  necessary  for  eighty-five  or  ninety  per  cent,  of  these 


904  Hospital  and  Health  Survey 

children  and  would  provide  for  from  one-third  to  one-half  of  the  repair 
service  necessary. 

The  grave  deficiency  of  dental  service  in  Cleveland  is  illustrated  by  the 
fact  that  the  total  clinic  provision  in  the  city  includes  only  that  at  the  three 
health  centers,  the  six  clinics  at  public  schools  and  the  dental  clinic  at  the 
City  Hospital,  a  total  of  ten  dental  chairs  running  156  hours  a  week.  In 
Boston  five  institutions  offer  either  free,  at  or  below  cost,  dental  service 
with  a  total  of  247  chairs  used  for  5,956  hours  a  week.  The  present  policy 
of  the  College  of  Dentistry  of  Western  Reserve  University  renders  it  hardly 
possible  to  class  it  with  public  service  clinics  for  dental  purposes.  (See 
Part  VIII.  of  Survey  Report,  page  685.) 

Dental  care  for  the  poor  in  Cleveland  is  limited  largely  to  extraction 
and  remedy  of  gross  pathological  conditions  causing  obvious  inconvenience 
or  pain.  Lack  of  knowledge  of  the  needs  and  possibilities  of  oral  hygiene  is 
responsible  for  the  neglected  teeth  of  most  dispensary  patients.  Dental 
clinics  where  a  small  fee  is  charged  are  badly  needed  in  the  congested  dis- 
tricts. 

It  is  strongly  recommended  that  dental  service  be  developed  as  an  activity 
of  all  the  health  centers,  including  the  central  downtown  dispensary,  and 
that  each  dispensary  connected  with  a  hospital  should  include  a  dental 
clinic  for  both  adults  and  children.  The  Survey  has  recommended  to  each 
of  the  major  hospitals  that  a  dental  surgeon  be  a  member  of  its  staff,  with 
rank  as  head  of  a  department;  and  that  under  his  direction  a  dental  clinic 
be  conducted,  with  the  necessary  dental  assistance.  Pay  dental  clinics  for 
persons  of  moderate  means  would  be  a  great  public  benefit. 

The  "Health  Centers" 

The  tuberculosis  and  infant  welfare  work  of  the  Division  of  Health  may 
be  studied  from  the  standpoint  of  the  management  of  its  clinics  as  well  as 
from  that  of  the  specialist  in  the  medico-social  problems  of  the  diseases 
concerned.  Of  the  eight  "Health  Centers,"  seven  include  tuberculosis 
clinics;  all  have  infant  welfare  clinics,  and  there  are  in  addition,  six  "baby 
prophylactic  stations,"  subsidiary  centers  for  the  better  covering  of  more 
neighborhoods. 

As  to  buildings,  three  of  the  Health  Centers  are  located  in  stores,  occu- 
pying the  entire  ground  floor  in  each  case.  Two  of  the  stores  have  light  from 
one  side  only;  one  of  these  two  has  good  light  from  the  rear.  The  third  store 
stands  on  a  lot  aloae  and  has  exc  Jlent  light  and  ventilation  on  all  sides.  All 
three  have  the  advantage  of  unusually  good  front  light.  These  three  cen- 
ters are  the  ones  selected  by  the  Mouth  Hygiene  Association  for  the  install- 
ment of  the  dental  work.  Three  other  centers,  Nos.  1,  3  and  4,  are  located 
in  single  dwelling  houses.  No.  4  has  the  entire  house  (allowing  a  man  and 
wife  to  occupy  the  upper  floor  in  exchange  for  the  care  of  the  store  fronts); 
all  the  rooms  have  some  daylight,  making  the  total  result  better  than  in  the 
stores.     Health  Center  No.  5  is  the  most  fortunately  located  of  all,  being 


Hospitals  and  Dispensaries  905 

in  a  public  bath-house,  which  is  also  a  gymnasium  and  social  club-house; 
there  are  here  ample  space  and  a  fortunate  arrangement  of  rooms.  No.  8,  the 
University  District  center,  is  in  half  of  a  double  house.  It  is  neither  very  light 
nor  roomy  and  arrangements  are  poor  for  the  work.  The  six  auxiliary  sta- 
tions are:  one  in  a  library — an  excellent  room  designed  for  a  kindergarten 
room;  one  in  a  Y.  W.  C.  A.  building;  one  in  a  community  center;  two  in 
public  bath-houses;  and  one  in  a  settlement  house.  One  of  the  public 
schools  in  the  downtown  section  is  used  in  the  summer  for  an  extra  station. 

All  the  clinics  are  limited  to  essential  equipment.  They  are  all  supplied 
with  imported  scales  for  weighing  the  babies  in  grams.  A  new  dental  equip- 
ment was  being  installed  in  Center  7  at  the  time  of  the  visit  of  the  Survey 
investigator.  The  buildings  were  not  adequately  heated  in  the  cases  of 
Nos.  7  and  3,  where  dependence  had  to  be  placed  on  stoves,  with  no  suitable 
place  to  store  coal.  Nos.  1  and  4  were  heated  by  gas  stoves  which  markedly 
affected  the  air. 

There  are  35  tuberculosis  clinics  a  week  held  in  the  seven  main  centers. 
University  District  does  the  home  visiting  on  tuberculosis  cases  in  its  area, 
but  gets  the  cases  from  the  clinics  held  at  Center  2.  These  clinics  are  held 
Monday,  Wednesday,  Friday  and  Saturday  afternoons  from  2  to  4  p.  m., 
and  Thursday  evenings  between  6 :30  and  7  p.  m. 

In  the  Child  Hygiene  Department  46  clinics  a  week  are  held.  Centers 
6  and  7  each  hold  six  clinics  a  week.  Center  2  and  the  auxiliary  station  at 
Alta  House  hold  two  each  a  week.  The  other  ten  stations  each  hold  clinics 
weekly.  These  clinics  are  held  between  9:30  and  10:30  a.m.  The  nurses 
reported  that  Saturday  was  always  the  least  crowded  day. 

Two  other  types  of  clinics  are  held  in  the  Health  Centers,  but  are  under 
auspices  somewhat  different  from  those  of  the  two  above  mentioned.  The 
district  doctors  hold  visiting  hours  in  three  of  the  clinics  from  9  to  10  a.  m. 
each  day.  An  average  of  about  six  patients  come  to  these  clinics  daily  for 
dressings,  or  to  get  advice  for  minor  ills.  The  number  is  frequently  two  to 
three  and  it  is  not  infrequent  for  the  doctor  to  have  not  a  single  caller. 

The  three  dental  clinics  maintained  by  the  Mouth  Hygiene  Association 
in  Centers  2,  6  and  7  meet  five  times  a  week  from  1  to  4  p.  m.,  and  are  largely 
used  by  parochial  school  children  and  the  families  of  patients  with  tuber- 
culosis. 

It  can  be  easily  seen  that  these  clinics  do  not  use  nearly  all  the  available 
daily  hours.  With  the  exception  of  Station  5  the  rooms  are  idle  during  the 
other  hours.  Stations  6  and  7,  both  of  which  have  infant  clinics  six  morn- 
ings a  week,  and  dental  clinics  every  afternoon  but  Saturday,  do  not  waste 
much  time,  but  the  other  buildings  could  serve  useful  purposes  at  other 
hours.     This  is  true  of  the  evening  hours  for  all  stations. 

The  patients  attending  the  clinics  are  derived  from  different  sources.  In 
a  study  made  of  a  series  of  cases  attending  the  Infant  Hygiene  Clinics,  57 


906  Hospital  and  Health  Survey 

per  cent,  were  found  to  be  referred  by  neighbors,  friends  or  relatives;  37 
per  cent,  referred  by  the  Health  Division  and  clinic  nurses;  2  per  cent,  by  the 
Visiting  Nurse  Association;  and  4  per  cent,  by  physicians.  The  practical 
value  of  the  work  is  rather  well  illustrated  by  the  large  number  of  cases 
sent  by  apparently  satisfied  clients.  In  considering  this,  the  use  of  the  clinic 
in  providing  an  inspected  milk  at  lower  than  market  prices  must  be  borne  in 
mind.  It  is*  not  purely  the  desire  for  a  health  inspection  for  their  children 
that  brings  the  mothers. 

In  the  tuberculosis  clinics  the  largest  percentage  came  in  as  a  result  of 
efforts  of  the  Division  of  Health  nurses,  46  per  cent,  having  come  in  this  way. 
14  per  cent,  were  referred  by  physicians  and  by  friends  or  relatives;  11  per 
cent,  by  dispensaries  and  hospitals,  7  per  cent,  by  the  Board  of  Education 
(referred  when  there  is  a  health  problem  in  relation  to  the  issue  of  working 
papers),  3  per  cent,  by  the  Associated  Charities,  and  1  per  cent,  each  from  the 
Red  Cross,  the  Juvenile  Court  and  the  Visiting  Nurse  Association.  The 
source  of  reference  for  the  other  cases  was  not  stated.  These  figures  do  not 
refer  to  active  or  positive  cases  only,  but  to  all  patients  that  came  to  the 
clinic  for  purposes  of  examination. 

There  were  about  three  times  as  many  visits  to  the  Infant  Hygiene 
clinics  as  to  the  tuberculosis  clinics  in  1918,  the  last  year  for  which  the  figures 
have  been  calculated.  This  attendance  is  out  of  proportion  to  the  number  of 
active  cases,  for  there  are  nearly  twice  as  many  active  cases  of  tuberculosis 
under  care,  as  cases  in  the  Infant  Hygiene  Clinics.  This  generous  attendance 
in  the  Infant  Hygiene  Clinics  is  doubtless  due  to  the  insistence  on  the  part 
of  the  clinic  that  the  baby  come  in  every  two  weeks  in  order  that  its  milk 
be  continued. 

In  the  Infant  Hygiene  work  the  nurses  give  much  assistance  in  the  clinics. 
They  weigh  each  baby,  suggest  to  the  mother  regarding  clothing  and  visit 
the  cases  at  home  to  instruct  in  milk  modification  when  this  seems  desirable. 
They  also  keep  the  milk  book.  This  is  a  big  job  as  well  as  a  very  large  book. 
Each  patient  has  to  be  graded  as  to  the  amount  he  shall  pay  for  milk.  There 
are  five  grades  similar  to  those  adopted  at  the  Babies'  Dispensary.  The 
nurses  have  not  established  quite  such  hard  and  fast  regulations  as  at  the 
Babies'  Dispensary,  but  are  free  to  exercise  some  judgment.  A  milk  that 
would  retail  at  30  cents  a  quart  is  sold  at  the  various  rates  according  to  the 
family  grade: 


Rate  l 

Rate  2 

Rate  3a. '.. 

Rate  36 

Rate  4 

'Synthetic  Milk  adapted. 


Cost  per 

Qt. 

Cost 

per 

Pt. 

Cost  S 

.  M.  A.*Qt. 

22c 

15c 

30c 

17c 

lie 

17c 

10c 

5c 

10c 

5c 

5c 

5c 

0 

0 

0 

Hospitals  and  Dispensaries  907 

Any  families  claiming  to  be  in  grade  4  who  are  not  referred  by  the  Asso- 
ciated Charities  are  cleared  through  the  Social  Service  Clearing  House  while 
the  patient  is  still  present.  Then  if  the  family  is  known  to  some  relief  agency 
the  agency  is  consulted  to  see  if  the  family  should  receive  free  milk.  The 
majority  of  families  are  in  rate  3a  or  3b.  S.  M.  A.  costs  40  cents  a  quart 
retail.  It  is  a  special  preparation  of  fats  and  oils  devised  by  Doctor  Ger- 
stenberger  and  prepared  in  the  milk  laboratories  of  the  Babies'  Dispensary. 

The  doctors  prescribe  the  milk  for  two-week  periods.  It  is  delivered  by 
the  Belle  Vernon  Farm  Company.  The  child  must  return  in  two  weeks 
or  the  milk  will  be  discontinued. 

Work  and  Personnel 

The  work  of  the  Health  Centers  may  be  divided  into  medical  and  nursing 
work.  The  type  of  work  for  each  group  must  be  divided  into  the  four  de- 
partments or  activities  of  the  clinics. 

Medical  Work 

The  medical  work  is  under  the  supervision  of  the  Commissioner  of  Health 
with  a  department  head  in  charge  of  each  branch.  At  present  the  Bureau  of 
Tuberculosis  has  no  chief.  The  Commissioner  of  Health  is  therefore  respon- 
sible for  its  activities.  He  is  not  able  to  give  the  health  centers  much  de- 
tailed supervision.  This  is  especially  unfortunate  because  there  are  no  spe- 
cial requirements  for  the  doctors  working  in  the  clinics  regarding  experience 
with  tuberculosis.  There  are  eight  physicians  in  the  Bureau,  each  receiving 
a  salary  of  $780  per  year  for  attending  five  clinic  sessions  weekly.  All  the 
cases  requiring  sanatorium  care  or  hospital  admission  are  passed  upon  by 
the  clinic  doctors.  The  medical  records  would  indicate  that  the  physicians 
made  a  careful  lung  examination  in  each  case.  Re-examinations  are  seldom 
recorded.  Sputum  analysis,  though  not  absolutely  routine,  is  fairly  fre- 
quent. Many  records  showed  that  the  patients  neglected  to  return  the 
bottles  given  out  for  collecting  sputum  specimens.  The  doctors  seemed 
interested  in  the  work  and  there  was  comparatively  little  complaint  among 
the  nurses  that  the  doctors  were  not  punctual.  Tonics,  cathartics  and  cod 
liver  oil  are  occasionally  prescribed  at  the  clinics. 

The  Chief  of  the  Bureau  of  Child  Hygiene  takes  an  active  part  in  the 
work.  He  personally  conducts  one  clinic  a  week  at  Center  5.  He  visits 
the  other  centers  rarely,  stating  that  all  the  doctors  on  duty  have  served  in 
the  Babies'  Dispensary  for  at  least  one  year  and  do  not  need  supervision. 
Much  of  the  rest  of  his  time  is  spent  in  the  drawing  of  charts  and  collecting 
statistics,  work  which  might  better  be  undertaken  in  the  Bureau  of  Vital 
Statistics.  His  salary  is  $3,300  a  year  and  he  devotes  his  full  time  to  the 
work.  The  Chief  of  this  Bureau  is  also  responsible  for  the  infant  eye  work 
and  the  inspection  of  boarding  homes  for  children.  These  two  functions 
have  been  so  far  systematized  as  to  require  practically  nothing  of  his  atten- 
tion. He  is  also  responsible  for  the  licensing  of  midwives,  but  this  is  not 
associated  with  the  clinic  work. 


908  Hospital  and  Health  Survey 

The  work  of  the  physicians  in  this  bureau  is  excellent  in  certain  respects, 
yet  lacks  much  that  would  make  it  of  vastly  greater  value.  The  babies  come 
to  the  clinic  and  are  undressed  and  weighed — they  are  then  dressed  before 
they  go  to  the  physician.  He  discusses  food  with  the  mother,  writes  a  pre- 
scription for  the  milk  the  child  will  need  for  the  next  two  weeks  and  fills  in 
its  formula  on  a  printed  detailed  slip.  If  the  mother  complains  that  the 
child  has  a  Qough,  she  is  advised  to  take  it  to  the  Babies'  Dispensary  where 
it  can  receive  a  chest  examination.  The  Survey  investigator  noted  the  fol- 
lowing case.  A  mother  brought  in  a  two-year-old  child,  very  thin  and  under- 
nourished and  unable  to  sleep.  A  private  doctor  had  told  the  mother  that 
it  had  worms  and  had  prescribed  medicine.  At  the  clinic  the  mother  was 
advised  to  return  to  the  private  doctor,  although  assured  that  the  child  did 
not  have  worms,  and  no  directions  were  given  regarding  diet  or  general  habits, 
which  were  admittedly  bad.  The  ability  to  prescribe  diet  for  infants  up  to 
15  months  is  highly  developed  in  the  clinic  physicians,  but  the  giving  of 
other  health  directions  and  the  diagnosing  of  cases  adequately  enough  to 
relieve  the  mother  from  trips  to  the  Babies'  Dispensary  are  not  usual.  The 
nurses  complained  of  the  difficulty  in  interesting  the  doctors  in  the  child  be- 
tween 3  and  6  years.  These  little  ones  are  allowed  to  come  to  the  clinic  for 
weighing  and  health  directions,  but  not  much  information  appears  to  be 
gained  from  the  doctors  which  is  of  aid  to  the  mothers. 

The  only  other  medical  work  done  in  the  stations  is  the  work  of  the  dis- 
trict physicians  who  make  their  headquarters  at  the  dispensaries.  They 
are  called  by  the  nurses  to  visit  various  cases  in  the  district,  including  con- 
tagious or  tuberculosis  cases,  as  occasion  may  require.  They  report  to  the 
center  each  evening  for  calls  that  have  been  left  there  during  the  day. 

Administrative  Work 

This  is  all  in  the  hands  of  the  supervising  nurses.  There  are  two  clerical 
assistants  in  each  center,  but  the  nurses  complained  that  few  of  them  were 
able  to  take  any  responsibility.  The  nurses  do  not  even  trust  the  care  of 
the  milk  book  and  the  collection  and  accounting  of  the  money  paid  for  milk 
in  the  clinics  to  these  helpers,  but  nurses  have  to  be  assigned  to  these  duties. 

Social  Work 

There  is  no  social  work  as  such.  All  cases  coming  to  the  tuberculosis 
cliiic  are  cleared  through  the  Social  Service  Clearing  House.  All  rate  3 
and  4  cases  coming  to  the  child  health  clinics  are  cleared.  Referring  and 
consulting  about  cases  depend  on  the  interest  and  understanding  of  the  nurse 
carrying  the  case.  All  the  rating  for  milk  is  done  by  the  nurses.  The  judg- 
ment used  varies  in  wisdom,  depending  on  the  nurse  doing  the  work.  The 
nurses  frequently  attempt  to  make  social  adjustments  in  a  distinctly  amateur 
way. 

Records  and  Filing 

A  system  of  filing  by  families  has  been  adopted  and  has  a  certain  distinct 
advantage.     One  number  is  given  to  the  family  and  each  additional  member 


Hospitals  and  Dispensaries  909 

who  comes  for  any  cause  gets  the  same  number  with  an  additional  letter. 
Thus  there  are  found  in  the  same  folder  case?  for  the  tuberculosis  clinic,  for 
infant  hygiene,  for  acute  eye  conditions,  and  possibly  for  a  contagious  condi- 
tion. But  keeping  families  in  groups  this  way  makes  necessary  a  rather 
elaborate  daily  attendance  book  and  careful  cross  indices.  It  is  convenient 
when  the  nurse  writes  up  the  record  and  keeps  all  the  records  of  each  family 
together.  Where  generil  home  visiting  is  so  vital  a  part  of  the  clinic  work 
it  seems  an  advisable  plan.  There  is  a  social  family  history  card  filled  out 
for  each  family  at  the  time  of  the  first  visit;  this  is  a  form  with  detiiled 
headings.  There  are  various  forms  for  the  different  departments.  The 
infant  hygiene  card  has  a  weight  chart  on  the  b  ick  and  is  similar  in  every  way 
to  the  card  used  at  the  Babies'  Dispensary.  There  are  special  forms  on  which 
diet  is  prescribed  which  are  worthy  of  notice.  There  are  forms  for  city  hos- 
pital admission  as  well  as  admission  to  Warrensville.  All  the  records  seemed 
to  be  well  filled  out  for  the  first  visit.  The  routine  recording  of  weight 
causes  the  dates  of  all  subsequent  visits  to  be  noted,  but  the  facts  observed 
by  the  doctors  were  not  always  recorded.  Each  nurse  keeps  a  daily  record 
of  her  work  and  detailed  monthly  reports  are  filed  at  the  Division  of  Health. 

Financial 

It  has  not  been  possible  to  obtain  from  the  Division  of  Health  an  itemized 
expense  account  of  the  Health  Centers  for  1919.  It  is  known  that  the 
expenses  for  the  year  from  the  three  departments  using  the  health  centers 
was  in  1919  as  follows: 

Total  Salaries 

Communicable  Diseases... $  53,526.97     $  31,171.84 

Tuberculosis 72,883.22         60,697.99 

Infant  Hygiene... r 65,330.05         53,352.09 


$191,740.24     $145,221.92 
The  rates  of  salaries  are  as  follows : 

Physicians 

Chiefs  of  Bureaus $3,300.  Full  time  (2) 

District  Physicians 3,300.  Full  time  (7) 

Tuberculosis  clinic — physicians 780.  5  clinics  (8) 

Infant  Hygiene  clinic — physicians 800.  6  clinics  (6) 

Infant  Hygiene  clinic — physicians 450.  3  clinics  (9) 

Nurses 

Director  of  field  nurses... $2 ,  400  Full  time  (1) 

Assistant  director ' 1,980  "        "    (1) 

Supervising  nurses 1  ,  660  "        "     ) 

Field  nurses — 2nd  year 1,440  "        "     [•(78) 

"          "        1st  year... 1,320  "        "    j 


910  Hospital  and  Health  Survey 


Clerical  Workers 

Senior  Typists $990  or  $1056  Full  time  (10) 

Junior  Typists 792  Full  time  (7) 

Almost  76  per  cent,  of  the  cost  of  the  work  goes  to  salaries.  There  is 
some  incom,e  from  the  work,  and  there  is  another  large  item  of  expense  not 
included  in  the  foregoing — that  is  the  milk,  as  mentioned  above.  The  milk 
report  for  one  month  showed  that  Rate  No.  1  overpaid  exact  cost  $106. 
Rate  No.  2,  by  buying  of  pints  instead  of  quarts,  overpaid  $1.83.  The  other 
grades  all  underpaid,  making  the  deficit  for  the  month  somewhat  over  $700. 
This  is  a  small  deficit;  it  is  usually  about  twice  that.  The  nurses  charge  $1 
or  50  cents  to  teach  milk  modification  at  home.  The  dental  work  is  charged 
for — Rate  1  pays  50  cents  each  time;  Rate  2  pays  50  cents  at  first  and  25 
cents  thereafter;  Rate  3a  pays  25  cents  first  and  25  cents  thereafter;  Rate 
3b  pays  25  cents  at  first  and  15  cents  thereafter;  and  Rate  4  gets  free  treat- 
ment.    These  dental  collections  go  to  the  Mouth  Hygiene  Association. 

Conclusions 

In  summary,  Cleveland  has  made  a  real  beginning  in  a  public  health  dis- 
pensary program.  Its  health  centers  meet  real  needs,  and  their  medical  and 
nursing  organization  provides  in  the  main  a  sound  foundation  both  for  im- 
provement in  details  of  service  and  for  future  advances  in  policy  and  scope. 
Aside  from  such  general  recommendations  regarding  dispensaries  as  appear 
in  the  next  section  of  this  chapter,  the  following  may  be  made  here : 

1.  There  should  be  coordination  between  the  publicly  and  privately 
supported  public  health  clinics;  notably  by  the  utilization  of  publicly  main- 
tained plants  (Health  Centers)  for  prenatal  clinics  (see  page  903).  This 
would  aid  in  utilizing  the  Health  Centers  to  their  capacity. 

2.  The  infanc  hygiene  work  should  include  children  up  to  six  years. 
The  present  limitation  of  work  to  infants  and  children  under  three  years 
of  age  is  a  great  misfortune.  With  little  additional  expense  better  care 
and  supervision  could  be  extended  to  the  children  up  to  six.  The  supply- 
ing of  milk,  a  daily  necessity  which  makes  return  to  the  clinic  vital,  has 
swelled  the  attendance  rather  than  improved  the  excellence  of  the  medical 
work  or  the  pertinence  of  the  health  directions.  This  milk  plan  is  doubtless 
wise  has  surely  resulted  in  preventing  much  illness  among  infants,  and 
should  be  continued;  but  it  should  be  a  relatively  smaller  part  of  the  clinic 
service.  The  doctors  should  develop  keener  and  more  intelligent  interest 
in  the  children  over  15  months,  and  should  be  prepared  to  write  out  as  accu- 
rate a  diet  for  them  as  for  the  younger  children. 

3.  The  division  line  between  the  sick  and  the  well  child  should  be  ex- 
tended a  little  in  favor  of  the  sick  child.  That  is,  the  doctors  should  more 
freely  make  examinations  and  give  at  least  health  directions  to  children  with 
colds.  Skin  conditions  are  another  bone  of  contention,  the  prophylactic 
center  doctor  feeling  they  are  "diseases"  and  should  go  to  the  Babies'  Dis- 


Hospitals  and  Dispensaries  911 


pensary,  and  the  Dispensary  feeling  that  the  mild  forms  belong  in  the  Health 
Centers. 

4.  The  Health  Centers  should  utilize  clerical  service  more  freely  for 
business  management  and  executive  details,  and  require  less  of  these  duties 
from  the  nurses.  The  recommendations  of  the  Nursing  Report  should  be 
followed  in  this  matter. 

5.  The  Centers  should  as  soon  as  possible  include  in  their  services  the 
examination  of  the  supposedly  well,  both  adults  and  children.  The  offer- 
ing of  such  periodical  "health  examinations"  may  perhaps  best  begin  in 
the  proposed  central  dispensary  (see  discussion  of  that  subject),  but  is  a 
proper  function,  ultimately,  of  all  health  centers. 

6.  Increase  in  the  number  of  dental  clinics  is  urgently  needed  as  recom- 
mende  i  in  Part  VIII.  of  the  Survey  Report. 

7.  The  Health  Centers  should  include  administrative  and  sanitary  activi- 
ties, such  as  properly  belong  to  a  local  office  of  a  Health  Division  under  a 
district  form  of  organization.  This,  as  well  as  the  much-needed  improve- 
ment in  supervision,  will  be  possible  only  with  an  advance  in  efficiency  of 
the  Division  of  Health,  its  better  organization,  and  larger  financial  sup- 
port. 


912  Hospital  and  Health  Sttrvey 

POLICIES  AND  NEEDS 

A  comparison  between  the  amount  of  dispensary  service  in  New  York, 
Boston  and  Cleveland  shows  a  startling  contrast.  The  115,000  dispensary 
visits  made  during  last  year  in  Cleveland  to  the  dispensaries  treating  the  sick 
must  be  compared  with  some  3,600,000  in  New  York  City  and  with  some 
750,000  in, Greater  Boston.  In  proportion  to  population,  Greater  Cleveland 
has  about  14  dispensary  visits  per  100  population.  New  York  about  60  per 
10.0,  and  Greater  Boston  about  50  per  100.  A  further  comparison  may  be 
made  with  Chicago,  which  in  1918  had  835,000  dispensary  visits  recorded, 
or  about  35  per  100  of  population.  It  will  be  seen  that  Cleveland's  provision 
is  extremely  low.  As  brought  out  in  the  early  part  of  this  report,  this  de- 
ficiency is  reflected  in  many  ways  in  hospital  service,  and  this  will  be  empha- 
sized in  the  following  sections  of  this  chapter;  but  the  shortage  of  dispensary 
service  also  means  for  the  community  as  a  whole,  deprivation  of  adequate 
medical  care  to  many  needy  groups  in  the  population,  lack  of  specialist 
service  to  many  more,  failure  to  diagnose  and  treat  many  diseases  during 
the  early  stages,  and  deprivation  of  consultant  and  diagnostic  facilities  to 
many  members  of  the  medical  profession. 

Preceding  a  statement  of  recommendations  for  improvements  or  increase 
of  service  to  meet  these  deficiencies,  a  statement  is  made  of  certain  policies 
regarding  dispensary  management  and  administration. 


DISPENSARY  POLICIES 
Admission  of  Patients 

(a)  Policy — In  determining  admission  to  a  dispensary,  the  needs  of  the 
patients  and  the  protection  of  the  community  must  be  the  primary  considera- 
tions. The  medical  profession  has  a  right  to  be  protected  against  imposi- 
tion by  persons  who  seek  in  clinics  the  unpaid  service  of  physicians,  when 
they  could  afford  to  pay  for  the  medical  care  which  they  need.  The  public 
has  a  right  to  service. 

(b)  Standards — In  determining  the  admission  of  individual  cases  to  a 
dispensary,  three  points  need  to  be  considered:  namely,  the  income  of  the 
patient  or  family,  the  size  and  responsibilities  of  the  family  according  to  a 
reasonable  standard  of  living,  and  the  character  and  probable  cost  of  ade- 
quate medical  treatment  for  the  disease  or  condition  found.  It  should  be 
added  that  under  certain  circumstances  public  health  considerations  must  be 
the  determining  factor,  for  example,  a  case  of  infectious  syphilis  may  demand 
immediate  treatment,  irrespective  of  what  later  disposition  of  the  case  is 
made.  When  a  difficult  or  obscure  condition  must  be  diagnosed,  or  when 
treatment  by  a  specialist  is  required,  patients  might  be  accepted  whose  cir- 
cumstances would  enable  them  to  pay  for  the  services  of  a  family  physician, 
though  not  for  consultation  with  or  care  by  specialists. 

(c)  Procedure — The  social  service  department  should  be  responsible 
for  the  admission  of  new  patients.  Certain  practical  points  connected  with 
this  matter  will  be  found  in  the  discussion  of  social  service. 


Hospitals  and  Dispensaries  913 


Medical  Relations 

(a)  Policy — The  medical  staff  of  the  dispensary  and  also  the  organized 
medical  profession  of  the  community  have  a  right  to  be  consulted  about 
policies  or  problems  affecting  their  interests.  In  the  case  of  the  general 
profession,  this  should  be  possible  through  conference  between  represent  i- 
tives  of  the  dispensary  and  representatives  of  the  Academy  of  Medicine. 
The  Central  Dispensary  Committee  hereinafter  proposed  (page  920)  would 
largely  accomplish  this  purpose. 

(6)  Compensation — Hospitals  and  dispensaries  cannot  expect  to  secure 
enough  of  prompt,  regular  and  efficient  medical  service  unless  compensation 
is  given  to  the  physicians  of  the  staff  either  in  opportunities  for  study  and 
experience,  or  in  financial  remuneration,  or  in  both.  The  generous  willing- 
ness of  physicians  to  render  humanitarian  service  is  traditional  and  unques- 
tioned, and  should  not  be  unduly  explpited.  Each  dispensary  or  out-patient 
department,  considering  its  own  type  of  work  and  the  medical  facilities 
offered,  must  determine  for  itself  the  manner  in  which  it  can  best  attract 
and  retain  an  adequate  medical  staff.  The  advice  of  central  bodies  such  as 
the  proposed  dispensary  committee  and  of  the  Cleveland  Academy  of  Medi- 
cine would  be  of  value  in  this  connection  from  time  to  time. 

(c)  Consultation — A  definite  function  of  the  dispensary,  particularly 
of  the  major  institutions,  is  to  provide  consultation  facilities  for  physicians. 

(d)  Diagnostic  Facilities — In  addition  to  opportunities  for  consulta- 
tion, dispensaries  should  make  the  services  of  their  laboratories  and  X-Ray 
departments  available  to  the  private  patients  of  physicians  (when  referred 
by  them)  when  such  patients  cannot  afford  the  rates  charged  by  private 
laboratories  or  by  X-Ray  specialists. 


Fees  from  Patients 

(a)  Policy — It  is  a  good  policy  to  charge  admission  fees  and  also  treat- 
ment and  medicine  fees;  no  patient  being  denied  a  needed  service  because  of 
inability  to  pay  the  stated  fee  in  whole  or  in  part. 

The  presence  of  medical  teaching  need  in  no  way  affect  this  policy. 

(/>)  Rates — For  clinics  receiving  the  gratuitous  services  of  physicians, 
an  admission  fee  of  25  cents  per  visit  is  reasonable  at  the  present  time.  It 
is  desirable  that  through  the  proposed  Central  Dispensary  Committee,  fees 
be  made  uniform  for  similar  classes  of  service. 

For  clinics  which  aim  to  be  self-supporting  and  whicl/furnish  a  more  than 
nominal  remuneration  for  the  physicians,  the  fee  should  be  not  less  than 
50  cents  a  visit,  and  may  be  higher  for  certain  classes  of  services.  The  basis 
on  which  such  fees  should  be  adjusted  is  the  cost  of  service. 


914  Hospital  and  Health  Survey 

Fees  for  special  treatments,  apparatus,  eye-glasses  and  medicines,  should 
be  fixed  at  or  somewhat  above  the  cost  of  the  materials  and  immediate 
service  provided. 

Definite  schedules  of  all  the  admission  and  the  more  usual  treatment  and 
medicine  fees  should  be  posted  in  suitable  places  in  every  dispensary. 

(c)  Pay  Clinics — Clinics  charging  fees  of  50  cents  or  more  a  visit  should 
be  regarded  as  pay  clinics  and  should  provide  financial  remuneration  for  their 
medical  staff.  In  determining  the  rates  of  such  remuneration,  conference 
with  representatives  of  the  Cleveland  Academy  of  Medicine  is  suggested, 
or  the  proposed  Central  Dispensary  Committee  would  serve  this  purpose. 

Such  pay  clinics  should  aim  to  serve  self-supporting  families  of  limited 
means,  particularly  in  the  specialties.  There  is  much  need  for  the  further 
development  of  such  clinics  in  Cleveland. 

The  admission  system  in  connection  with  pay  clinics  should  protect  the 
interests  of  the  medical  profession  as  well  as  of  the  patient  by  adopting  and 
carrying  out  the  standards  above  outlined. 

(d)  Remission  of  Fees — The  admission  desk  in  the  smaller  dispensaries 
should  be  responsible  for  the  remission  of  all  fees.  In  large  dispensaries  the 
admission  desk  may  be  unable  to  attend  to  all  remissions  in  the  case  of  old 
patients,  and  social  workers  in  one  or  more  clinics  should  be  authorized  to 
pass  on  remissions  for  the  appropriate  group  of  cases. 

Adaptation  of  Clinics  to  Clientele 

(a)  Hours — Evening  clinics  for  working  people  are  desirable  in  all  or 
almost  all  dispensaries.     These  clinics  may  well  be  pay  clinics. 

(6)  Foreign-Speaking  Patients — Special  efforts,  as  outlined  in  the 
discussion  of  the  foreign -born,  in  the  section  on  the  "Human  Problem  of  the 
Hospital  Patient,"  should  be  made  to  enable  persons  not  speaking  English 
to  receive  effective  treatment. 

(c)  One  important  group  of  the  clientele  of  nearly  all  dispensaries  is  that 
of  the  beneficiaries  of  other  charitable  or  medical  agencies.  It  is  part  of  the 
duty  of  a  dispensary  to  serve  as  the  family  physician  for  these.  This  re- 
quires: (1)  examination  of  patients  and  families  and  full  reporting  of  condi- 
tions found  to  the  society  interested;  (2)  treatment  of  those  needing  care, 
usually  without  fee;  (3)  special  arrangement  whereby  the  social  service  de- 
partment of  the  dispensary  has  charge  of  "steering"  these  cases  and  insuring 
that  the  work  is  done  and  the  reports  are  rendered  with  a  minimum  of  admin- 
istrative demand  upon  the  clinic  physician. 

(d)  The  dispensary  should  be  a  main  agent  in  the  admission  of  hospital 
patients  to  the  wards  and  in  the  follow-up  of  those  discharged.  (See  sec- 
tions on  Convalescent  Care  ) 


Hospitals  and  Dispensaries  915 


Inter-relations  of  Dispensaries 

(a)  Duplication — The  pursuance  of  treatment  by  a  patient  or  the 
members  of  a  family  at  more  than  one  dispensary  at  the  same  time  should 
be  discouraged  and  prevented  as  far  as  possible  by  careful  admission  systems. 
The  inquiry  at  the  admission  desk  should  include  question  as  to  place  or 
agency  of  previous  treatment. 

(6)  Reference  of  Patients — Patients  recently  under  treatment  it 
one  dispensary  .  and  not  specifically  referred  to  another  for  consultation, 
should  be  referred  back  to  their  former  place  of  treatment,  except  when  satis- 
factory reason  is  found  to  exist  for  the  transfer.  The  same  policy  should  of 
course  be  pursued  when  a  patient  has  been  under  treatment  by  a  private 
physician. 

The  use  of  printed  or  written  slips  of  reference  is  of  practical  oervice. 

(c)  Districting — The  limitation  of  the  work  of  each  dispensary  treat- 
ing the  sick  to  a  definite  area  is  not  practicable,  but  patients  should  be  en- 
couraged to  seek  treatment  in  the  section  of  the  city  in  which  they  reside  or 
have  their  place  of  business.  Well  administered  admission  systems  at  each 
dispensary  and  a  common  understanding  of  policy,  worked  out  by  the- pro- 
posed central  committee,  should  reduce  to  a  minimum  problems  of  dupli- 
cation and  of  overlapping  of  areas. 


Dispensary  Administration 

Essential  points  of  organization  are  presented  in  the  sections  on  "Organ- 
ization for  Service"  and  "The  Medical  Profession  and  the  Hospitals,"  and 
will  be  merely  recapitulated  here: 

An  executive  head  for  the  dispensary. 

A  medical  organization  which  is  integrated  with  that  of  the  hospital. 

A  dispensary  medical  committee. 

A  dispensary  committee  of  the  board  of  trustees  or,  if  the  board  has 
not  a  sub-committee  system,  one  or  more  members  of  the  executive  com- 
mittee who  have  special  responsibility  to  be  in  touch  with  the  dispensary. 

The  dispensaries  of  Cleveland  would  do  well  to  develop  carefully  worked 
out  systems  of  referring  patients  from  clinic  to  clinic  within  the  dispensary, 
for  consultation  purposes;  and  for  transferring  patients  for  treatment  from 
one  clinic  to  another,  with  due  report  back  to  the  referring  or  transferring 
clinic. 

The  important  place  of  the  social  service  department  in  dispensaries  is 
outlined  in  the  section  devoted  to  social  service. 


916  Hospital  and  Health  Survey 


Medical  Care  of  Children  in  Foster  Homes 

This  has  received  little  attention  from  the  medical  agencies  of  Cleve- 
land, and  the  Humane  Society  itself  has  not  dealt  adequately  with  its  re- 
sponsibility in  this  matter.  As  Dr.  Mac  Adani's  report  shows,  in  another 
portion  of  the  Survey  (Part  II.),  the  physical  condition  of  the  children 
boarded  out  £>y  the  Humane  Society  is  far  from  satisfactory.  Moreover,  the 
Society's  records  do  not  show  adequate  medical  supervision  of  its  children, 
and  indeed  the  system  which  it  pursues  would  render  adequate  medical  work 
quite  unlikely.  Even  in  the  case  of  the  children  under  three  years  of  age, 
which  are  within  the  special  province  of  the  Babies'  Dispensary  and  which 
are  supervised  thereby  in  behalf  of  the  Society,  results  are  not  satisfactory. 
This  is  largely  because  of  the  lack  of  a  really  intimate  affiliation,  which  is 
required  for  the  successful  conduct  of  any  such  piece  of  work.  It  is  essential 
that  the  physicians  of  any  dispensary  vhich  is  served  in  such  a  capacity 
shall  think  of  the  special  problems  of  a  placing-ort  society,  as  well  as  of  the 
physical  needs  of  each  individual  baby.  The  social  workers  and  nurses  who 
are  in  touch  with  the  foster  home  need  special  explanation  of  the  child's 
needs  in  terms  that  they  can  understand,  and  the  foster  mothers  need  in- 
struction not  only  from  the  field  workers  but  also,  from  time  to  time,  from 
the  physician  himself.  Moreover,  the  administrative  system  of  the  dispen- 
sary must  be  specially  adapted  to  this  work  for  the  placing-out  society. 
Delays  must  be  minimized  and  records  and  information  be  readily  and 
promptly  secured. 

In  the  case  of  the  older  children,  present  conditions  are  still  less  satisfac- 
tory than  with  the  babies. 

Satisfactory  results  cannot  be  expected  unless  the  Society  has  a  Medical 
Director,  who  should  be  a  specialist  in  pediatrics,  and  be  responsible  for  the 
medical  standards  and  policies  of  all  children  under  the  care  of  the  Society. 
This  director  should  be  a  member  of  the  staff  of  the  children's  clinic  of  a  dis- 
pensary with  which  the  Society  makes  a  working  arrangement  for  the  initial 
examination,  re-examination  and  much  of  the  interim  supervision  of  the 
children's  health.  Preferably  he  should  be  also  on  the  staff  of  a  hospital 
with  a  pediatric  service  so  that  sick  children  requiring  hospitalization  could 
be  still  under  his  care.  There  are  substantial  advantages  in  utilizing  for 
examination  and  supervision  the  equipment,  organization  and  the  group 
of  specialists  of  a  well  managed  dispensary,  instead  of  a  number  of  doctors 
in  separate  private  offices.  The  systems  worked  out  in  Boston,  by  coopera- 
tion between  the  Children's  Aid  Society  and  the  Boston  Dispensary,  and  in 
Philadelphia  by  the  Seybert  Institution,  could  be  studied  to  advantage  as 
illustrations  of  method. 

It  is  important  that  there  shall  be  not  only  intimate  coordination  between 
the  medical  authority  of  the  Humane  Society  and  the  medical  agents  and 
agencies  doing  the  actual  work,  but  also  that  the  nursing  and  social  service 
staffs  be  in  similarly  close  touch.  Without  this,  satisfactory  results  cannot 
be  expected.  The  medical  workers  and  the  field  workers  must  understand 
one  another  and  the  system  under  which  each  group  works  must  be  mutually 
adapted  to  achieve  the  needed  degree  of  mutual  understanding. 


Hospitals  and  Dispensaries  917 

It  is  recommended  that: 

1.  A  medical  director,  a  pediatrician,  be  appointed  by  the  Humane 
Society,  with  a  financial  honorarium,  as  the  authoritative  guide  and  super- 
visor of  the  physical  condition  and  development  of  all  its  children 

2.  This  director  be  a  member  of  the  staff  of  either  the  Babies'  Dispensary 
or  of  the  proposed  central  downtown  dispensary  (Pediatric  Clinic),  whichever 
the  Humane  Society  decides  to  be  the  better  organization  for  such  affiliation. 

3.  Routine  medical  examination,  re-examination,  advice  and  super- 
vision of  health  be  carried  out  through  the  selected  clinic,  a  special  salaried 
medical  assistant  being  requisite  for  the  purpose.  The  Humane  Society 
should  provide  this  salary. 

4.  Standards  for  medical  examination,  hygienic  directions,  diet,  re-visits, 
home  care  in  emergencies,  etc.,  be  outlined  by  the  medical  director. 

5.  Consultation  by  the  specialists  in  other  departments  of  the  selected 
dispensary  (eye,  dental,  throat,  ear,  skin,  orthopedic,  etc.)  be  provided  as 
requested  by  the  medical  director;   treatment  also  as  necessary. 

6.  The  use  of  the  local  doctors  and  of  specialists  in  private  offices  be 
reduced  to  a  minimum;  that  reports  from  such  physicians  be  required  and 
made  part  of  the  central  medical  record. 

7.  A  special  worker  be  in  the  selected  pediatric  clinic,  under  the  adminis- 
trative direction  of  the  clinic,  but  with  salary  wholly  or  largely  from  the 
Humane  Society,  to  attend  to  the  details  of  assisting  in  securing  examinations 
and  consultations;  in  effecting  transfers;  keeping  track  of  needed  re- visits; 
and  seeing  that  the  necessary  information  is  furnished  by  the  Society  to  the 
clinic  doctors  and  workers  on  the  one  hand,  and  by  the  clinic  to  the  field 
workers  and  foster-mothers  on  the  other. 

8.  Periodic  conferences  between  the  medical  director  and  his  assistant 
or  assistants,  be  held  with  the  clinic  worker  and  the  field  nurses  and  social 
workers  who  deal  with  the  Society's  cases. 

9.  The  records  of  the  clinic  concerning  each  child  be  regularly  furnished 
the  Society  and  the  clinic  be  provided  by  the  Society  with  such  history  of 
each  case  as  the  medical  interests  require.  Record  forms  should  be  espe- 
cially prepared  for  this  purpose. 

10.  The  present  system  of  utilizing  public  health  nurses  for  home  visit- 
ing of  placed-out  children  be  continued  and  made  much  more  effective  through 
(a)  the  centralized  medical  direction  contemplated  in  the  plan  (b)  the  closer 
medical  supervision  provided  for  in  recommendations  3,  7  and  8. 

If  the  Babies'  Dispensary  will  increase  its  age  limit  and  render  its  organ- 
ization sufficiently  flexible  and  adaptable  to  meet  the  requirements  of  effi- 
cient service  to  this  group  of  children,  it  would  be  desirable  that  the  plan  be 
worked  out  by  the  Society  in  cooperation  therewith.      The   establishment 


918  Hospital  and  Health  Survey 

of  some  special  clinics  as  well  as  the  general  pediatric  clinic  would  be  neces- 
sary, as  the  Survey  has  recommended  in  its  special  report  to  the  trustees  of 
this  institution.  If  the  requisite  conditions  cannot  be  met  at  the  Babies' 
Dispensary,  it  is  recommended  that  the  central  downtown  dispensary  be 
utilized. 

It  should  be  pointed  out,  in  conclusion,  that  while  the  proposed  plan 
for  adequate  medical  supervision  of  placed-out  children  will  cost  more  than 
the  present  admittedly  inadequate  system,  the  expense  of  the  medical  work 
is  after  all  only  a  small  fraction  of  the  total  cost  of  boarding  and  general  super- 
vision of  such  children.  Very  little  permanent  result  for  the  present  or  the 
future  generation  can  follow  from  any  system  of  children's  aid  which  does 
not  make  the  thorough  and  efficient  care  of  health  a  primary  consideration. 


DISPENSARY  NEEDS  OF  CLEVELAND 

Aside  from  the  public  health  dispensaries  for  which  recommendations 
were  made  in  the  previous  section  of  the  report,  the  dispensaries  for  the 
treating  the  sick  of  Cleveland  universally  need  improvement  in  various 
respects.  Recommendations  regarding  each  institution  have  been  presented 
to  its  governing  body  by  the  Survey.  In  general,  the  needs  may  be  sum- 
marized as:  (1)  more  work  to  be  done;  (2)  better  executive  direction  through 
the  assignment  of  a  definite  officer  to  be  in  charge  of  the  dispensary,  under 
the  superintendent;  (3)  representation  of  the  out-patient  department  so  as 
to  secure  better  recognition  of  it  by  the  hospital  authorities;  (4)  paid  assist- 
ants for  the  medical  staff  (social  workers,  nurses,  clerks)  so  as  to  relieve  the 
physicians  of  non-medical  drudgery  and  improve  the  grade  of  service  to 
patients;  (5)  better  records  which,  would  largely  be  accomplished  by^the 
assistants  just  mentioned;    (6)  better  plants  and  equipment. 

The  expense  involved  in  the  improvement  of  services  lies  chiefly  in  the 
salary  of  ths  paid  assistants  mentioned,  and  would  be  largely  met  by  the 
admission  fees  recommended. 

An  increase  in  the  amount  of  dispensary  service  for  the  people  of  Cleve- 
land is  as  greatly  needed  as  is  an  improvement  in  the  quality  of  service  now 
offered.  It  may  be  expected  that  the  work  of  existing  dispensariss  will  in- 
crease considerably  as  more  attention  is  paid  to  their  needs,  and  better  sup- 
port is  provided.  But  no  increase  in  the  work  of  the  six  present  institutions 
can  obviate  the  necessity  of  at  least  the  following  additional  dispensaries: 

The  City  Hospital  out-patient  department  is  already  provided  for  in 
the  tentative  plans  for  the  enlarged  City  Hospital.  It  should  be  one  of  the 
major  dispensaries  of  the  city.     (See  section  on  "Community  Planning"). 

St.  John's  Hospital  should,  as  soon  as  possible,  develop  a  good-sized 
out-patient  department  for  the  benefit  both  of  the  hospital  and  of  the  west 
side  area  which  it  especially  serves  and  which  now  has  no  dispensary. 

When  the  re-organization  and  development  at  St.  Alexis  Hospital  have 
been  worked  out  under  the  new  advisory  committee,  the  establishment  of  a 


Hospitals  and  Dispensaries  919 

well-equipped  out-patient  department  should  be  undertaken  and  this  need 
should  be  borne  in  mind  by  the  committee  even  in  the  formulation  of  its 
plans  for  the  immediate  future. 

The  establishment  of  an  out-patient  department,  now  being  built  by 
Fairview  Park  Hospital  is  approved,  although  this  dispensary  will  prob- 
ably remain  small  and  its  work  restricted  largely  to  certain  types  of  cases, 
particularly  surgical,  corresponding  to  the  work  of  the  hospital. 

The  same  would  probably  be  true  of  similar  out-patient  departments  that 
might  well  grow  up  in  connection  with  other  hospitals  of  the  same  type  in 
the  same  section  of  the  city,  such  as  Grace  Hospital  or  Lutheran. 

The  plans  for  the  re-location  of  Lakeside  Hospital  imply  a  new  dis- 
pensary, attached  to  its  new  plant.  This  should  be  another  of  the  few 
major  dispensaries,  as  described  in  the  community  plan,  in  the  section  on 
that  subject. 

The  proposed  new  plant  of  St.  Luke's  Hospital  will  require  a  dispen- 
sary, unless  the  present  buildings  or  parts  thereof,  are  retained  as  an  indus- 
trial hospital,  and  a  dispensary  be  operated  in  connection  therewith.  The 
latter  plan  is  recommended. 

It  is  not  believed  that  the  proposed  new  plant  of  Huron  Road  Hospital 
on  Ambler  Heights  will  require  a  dispensary  for  some  years  to  come;  but 
Huron  Road  might  with  advantage  have  at  least  a  medical  affiliation  with 
the  proposed  central  downtown  dispensary.  (See  section  on  downtown 
dispensary.) 

A  new  dispensary  will  be  needed  downtown,  at  least  as  soon  as  Lake- 
side and  Huron  Road  move  out,  and  meanwhile,  certain  services  for  the 
downtown  area  need  immediate  development. 

Cleveland,  like  most  other  cities,  suffers  from  lack  of  any  general  plan 
for  dispensary  service.  The  different  clinics  are  not  coordinated  with  one 
another  or  with  the  public  health  and  charitable  agencies.  It  is  essential  to 
have  a  plan  and  effective  organization  whereby  the  work  of  existing  dispen- 
saries shall  be  improved  and  the  new  dispensaries  be  established  in  sections 
of  the  city  now  unprovided  for.  But  above  all,  the  aim  must  be  to  furnish  a 
basis  upon  which  dispensary  service  should  be  better  understood  by  the  com- 
munity and  better  serve  the  community.  The  points  of  view  of  the  prac- 
titioner of  medicine,  of  business,  and  of  charitable  agencies,  of  the  men, 
women  and  children  who  need  adequate  service  and  cannot  pay  for  it,  and 
of  the  public  as  a  whole,  represented  by  the  city  government  and  organized 
agencies  for  expression,  all  need  to  be  considered  in  framing  any  forward- 
looking  project  of  this  character.  The  preventive  and  educational  work  of 
the  health  centers  must  be  adjusted  in  conjunction  with  the  curative  medical 
work  of  the  hospital  out-patient  departments,  so  as  to  be  mutually  helpful 
and  to  serve  as  parts  of  a  developing  city  plan. 


920  Hospital  axd  Health  Survey 


It  is  necessary — 

(a)  To  create  some  group  of  people  or  machinery  whereby  the  dis- 
pensary problems  of  the  city  can  be  viewed  as  a  whole,  each  particular  dis- 
pensary or  related  agency  be  brought  into  touch  with  the  larger  problems, 
and  the  larger  problems  themselves  directly  and  adequately  dealt  with. 

(6)  To  have  dispensary  work  rest  upon  its  own  financial  basis — the 
financial  support  of  dispensary  service  being  provided  in  terms  of  and  in  pro- 
portion to  such  service,  and  not  merely  as  a  part  of  hospital  or  medical  work 
in  general. 

It  is  therefore  proposed: 

1.  That  there  be  a  Dispensary  Section  or  Committee  of  the  Hospita 
Council — this  committee  or  section  to  include  representatives  from  each  of 
the  existing  out-patient  departments  of  those  hospitals  which  are  mem- 
bers of  the  Council;  and  also  representatives  from  the  Department  of  Public 
Welfare,  the  Cleveland  Academy  of  Medicine,  and  persons  interested  in 
visiting  nursing  and  charitable  agencies. 

2.  That  there  be  a  salaried  executive  officer  for  this  Dispensary  Sec- 
tion or  Committee  of  the  Hospital  Council.  Such  officer  at  first  might  be 
required  only  for  part  time  and  in  that  case  had  best  be  selected  from  some 
organization  other  than  one  of  the  privately  operated  out-patient  depart- 
ments. 

3.  That  the  Cleveland  Welfare  Federation  require  the  presentation  of 
request  for  support  for  the  out-patient  departments  of  hospitals  to  be  made 
separately  from  the  request  for  support  for  hospital  work  proper;  such  re- 
quests to  show  the  work  done  by  the  dispensary,  the  cost  thereof  (includ- 
ing a  fair  allowance  for  overhead)  and  the  income  of  the  dispensary  from 
fees  paid  by  patients  or  from  other  sources. 

In  view  of  the  general  importance  of  dispensaries  to  the  community, 
and  of  their  special  service  as  the  "'family  physicians"  of  the  non-medical 
charities,  the  Welfare  Federation  should  appropriate  monies  to  dispensaries 
('the  out-patient  departments  of  hospitals)  on  the  basis  of  reports  of  (1)  work 
done,  (2)  gross  expenses  incurred,  (3)  net  expense  after  deducting  all  dispen- 
sary income  from  fees,  special  endowment,  etc.  This  would  mean  a  con- 
sideration of  the  annual  dispensary  budgets  as  separate  parts  of  the  budgets 
of  the  hospitals  to  which  the  dispensaries  are  attached.  It  would  cause  ap- 
propriating, supervisory  and  administrative  bodies  to  give  much  more  atten- 
tion to  the  dispensaries,  which  have  too  often  been  regarded  as  merely  inci- 
dental elements  in  a  hospital. 

Cleveland  ought  to  have  at  least  three  times  as  much  dispensary  service 
as  it  now  has.  In  from  three  to  five  years  this  goal  can  be  attained,  through 
the  enlargement  and  improvement  of  existing  dispensaries  and  the  addition 
of  new  ones  at  the  City  Hospital  and  on  the  west  and  south  sides.  The 
gross  cost  of  adequate  dispensary  service  to  Cleveland,  at  present  costs  of 


Hospitals  and  Dispensaries  921 

maintenance,  would  probably  be  over  $300,000  annually.  The  present  gross 
cost  is  not  over  $75,000  (charging  in  all  overhead).  The  difference  is  due 
partly  to  the  limited  amount  of  work  and  partly  to  low  standards.  It  should 
be  expected  that  when  proper  fee  systems  are  developed,  50  per  cent,  of  the 
gross  cost  should  be  met  by  fees  from  patients. 

It  is  thus  contemplated  that  the  Dispensary  Committee  or  Section  of 
the  Hospital  Council  should  be  an  expert  advisory  and  planning  body,  serv- 
ing to  improve  dispensary  standards  and  administration  of  the  several  insti- 
tutions  to  work  out  the  larger  problems  of  policy  and  inter-relation,  and  to 
serve  also  as  an  advisory  body  for  the  Welfare  Federation,  as  the  Hospital 
Council  now  does.  The  financial  standing  given  to  dispensary  work  by  the 
proposed  action  of  the  Welfare  Fedention  would  be  essential  if  dispensary 
service  is  to  stand  on  its  own  feet. 

No  such  Dispensary  Section  or  Committee  could  be  effectnre  unless  some 
definite  salaried  executive  assistance  is  provided. 

More  and  better  dispensary  service  is  one  of  the  impo/tj.nt  medical  needs 
of  Cleveland.  The  Hospital  Council  and  the  Welfare  Federation  should 
recognize  it  as  such. 


922  Hospital  and  Health  Survey 


THE  CENTRAL  DOWNTOWN  DISPENSARY 

The  central  downtown  district  of  the  city  presents  needs  for  medical 
and  health  service  which  are  now  not  met,  and  offers  certain  unique  oppor- 
tunities for  rendering  many  forms  of  service.  Huron  Road  Dispensary  is 
excellently  located,  but  the  present  dispensary  is  very  small,  and  is  in  cramped 
quarters  which  permit  but  slight  expansion,  while  the  hospital  continues  as 
at  present.  Lakeside  Dispensary,  while  not  as  well  located,  though  still 
fairly  accessible  to  the  central  downtown  area,  has  far  more  possibilities,  but 
as  yet  has  not  measured  up  to  its  opportunities.  The  moving  out  of  both  of 
these  institutions  will  require  either  the  retention  of  one  plant  is  a  central 
downtown  dispensary,  and  the  maintenance  in  this  plant  of  needed  forms  of 
service  not  now  provided,  or  the  establishment  of  a  new  plant. 

In  the  first  place,  it  is  desirable  to  state  the  needs  to  be  met.  The  centr  il 
downtown  district  of  the  city  requires  dispensary  service  within  its  own 
area  for  at  least  four  reasons : 

(a)  Emergency  and  industrial  surgical  work  arising  from  the  large  day- 
time commercial  and  industrial  population  of  the  central  area  of  the  city. 

(6)  Many  special  forms  of  medical  services  which  for  the  public  wel- 
fare should  reach  as  many  persons  as  possible,  and  which  in  the  downtown 
area  can  be  brought  to  the  attention  of  the  large  daytime  and  evening  popu- 
lation which  throngs  this  district  for  business  or  recreational  purposes. 
Clinics  in  this  district  held  at  certain  hours  of  the  day,  for  instance  at  luncheon 
time  and  in  the  evenings,  would  reach  large  numbers  of  persons  who  are  prac- 
tically inaccessible  otherwise.  Tuberculosis  Clinics,  Venereal  Clinics,  or 
Mental  Hygiene  Clinics,  are  examples. 

(c)  General  medical  and  also  special  services  such  as  are  provided  by 
general  dispensaries,  ought  to  be  available  to  this  transient  population  of 
the  central  area  (as  well  as  to  its  residents)  at  hours  and  under  conditions 
which  would  make  it  possible  to  have  these  services  most  effectively  used  by 
those  who  most  need  them. 

(t/)  This  dispensary  would  serve  charitable  agencies,  providing  medical 
examination  and  supervision  for  the  families  under  care  in  the  central  dis- 
trict, or  who  have  to  be  brought  to  this  district  to  the  society's  offices.  Cases 
requiring  elaborate  study  or  special  treatment  would  be  referred  to  one  of 
the  major  out-patient  departments. 

The  downtown  dispensary  is  required  for  a  larger  reason.  If  properly 
organized  and  made  a  real  center  of  a  variety  of  health  and  medical  activities 
such  a  downtown  dispensary  would  serve  as  an  important  educational  center 
along  general  health  lines,  assisting  the  work  of  many  other  agencies,  not 
only  as  a  point  from  which  patients  would  be  referred  but  also  as  a  center 
of  public  health  education. 


Hospitals  and  Dispensaries  923 

Such  a  dispensary  would  include: 

(a)  A  clinic  for  industrial  surgery  operated  throughout  the  twenty- 
four  hours.  Such  a  clinic  would  require  special  arrangements  for  its  pro- 
fessional services  and  be  administered  so  that  patients  could  be  admitted 
without  delay,  although  the  clinic  might  be  closely  related  to  the  other 
dispensary  services  in  the  same  building.  The  need  for  such  an  industrial 
clinic  has  been  brought  out  in  Part  VII.  of  the  Survey  Report. 

(6)  A  Health  Center  of  the  City  Division  of  Health  maintaining  (1)  a 
tuberculosis  clinic,  with  a  special  consultation  service  at  periodical  inter- 
vals, (2)  venereal  clinics,  and  (3)  a  division  for  health  education,  which  should 
include  among  its  activities  the  conduct  of  a  clinic  for  the  examination  of 
well  people — children  and  adults.  It  might  perhaps  be  best  to  maintain 
the  venereal  clinics  under  private  auspices.     (See  Part  V.) 

(c)  A  mental  hygiene  clinic. 

(c?)  A  general  medical  clinic  for  the  examination  and  treatment  of  sick 
persons. 

(e)  Special  clinics,  such  as  eye,  ear,  nose  and  throat,  and  surgery,  (other 
than  industrial  surgery). 

(/)  The  "Orthopedic  base"  or  "center"  recommended  in  the  orthopedic 
plan,  (Part  II  of  the  Survey  Report),  should  be  in  the  same  building.  Its 
work  would  assist  all  the  other  branches  in  the  downtown  dispensary  and 
would  be  assisted  by  them.  This  orthopedic  center  would  include,  besides 
certain  administrative  functions  relating  to  the  orthopedic  plan  of  the  city 
as  a  whole,  a  physical  treatment  center  which  would  be  of  city-wide  value 
and  would  be  especially  advantageous  if  located  in  this  central  district. 

(g)  The  affiliation  of  this  downtown  health  center  with  the  University 
is  highly  desirable. 

It  has  been  pointed  out  elsewhere  that  there  is  needed  a  certain  small 
number  of  hospital  beds  (20  to  50)  in  the  central  downtown  area,  largely  for 
emergency  purposes.  This  emergency  hospital  or  "relief  station"  could  with 
advantage  be  combined  with  the  central  downtown  dispensary. 

If  both  Huron  Road  and  Lakeside  Hospitals  move  to  their  new  sites 
within  a  few  years  the  proposed  dispensary  and  the  emergency  beds  will  be 
the  more  urgently  required.  The  plant  of  Huron  Road  Hospital  appears  to 
be  suitable,  with  relatively  slight  modifications,  for  the  combined  purposes 
of  emergency  beds  (30  to  40  in  number)  and  the  downtown  dispensary.  The 
location  is  almost  ideal.  It  might  be  well  for  Huron  Road  Hospital,  as  well 
as  for  the  public  good,  that  there  be  a  medical  affiliation  between  the  Huron 
Road  staff  and  the  dispensary  staff;  but  the  problem  of  staff  for  the  down- 
town dispensary  might  be  solved  in  other  ways. 

The  industrial  surgical  clinic  should  be  fully  self-supporting,  from  the  in- 
dustries which  it  serves  and  from  the  workmen's  compensation  cases.    The 


924  Hospital  and  Health  Survey 

staff  of  this  division  should  be  salaried.     The  senior  visiting  staff  would  pro- 
vide certain  supervisory  and  consultant  advantages. 

The  public  health  clinics  of  the  dispensary  would  constitute  an  additional 
Health  Center  of  the  city  Division  of  Health,  and  would  require  the  neces- 
sary addition  to  its  budget.  The  mental  disease  and  mental  hygiene  clinic 
should  be  maintained,  at  least  at  the  start,  by  the  organization  especially 
concerned  with  this  interest.  The  orthopedic  clinics  and  physical  treatment 
center  should  be  supported  likewise  by  the  orthopedic  group  referred  to  else- 
where in  the  Survey  report  (Part  II.) 

The  Community  Fund  would  properly  be  called  on  for  the  financial  sup- 
port of  the  general  medical  clinics  for  adults  and  for  children,  and  for  the 
special  clinics  which  are  required.  Xot  only  as  meeting  a  general  public 
need  and  a  broad  purpose  in  health  education,  but  also  as  assisting  charitable 
societies  to  secure  better  medical  examination,  advice  and  supervision  for 
their  beneficiaries,  the  central  downtown  dispensary  has  a  peculiar  demand 
upon  the  Welfare  Federation.  This  dispensary,  among  other  benefits, 
would  make  money  spent  for  many  other  charitable  agencies  count  for  more. 

In  estimating  the  cost  of  this  dispensary,  it  must  be  borne  in  mind  that 
the  medical  staff  in  all  clinics  should  receive  financial  compensation,  except 
for  merely  consultant  or  infrequent  visiting  services.  The  gross  maintenance 
expense  of  conducting  the  industrial  surgical  clinic,  public  health  clinics, 
general  medical,  pediatric  and  special  clinics,  with  a  used  capacity  of  50,000 
visits  a  year,  should  not  exceed  $60,000.  Deducting  the  cost  of  the  industrial 
and  the  public  health  clinics  supported  by  industry  and  by  the  city,  respec- 
tively, the  gross  charge  upon  private  funds  would  be  about  $35,000,  of  which 
some  $15,000  might  be  expected  to  be  returned  through  fees  from  patients. 
The  net  charge  should  not  exceed  $20,000  a  year. 

It  is  apparent  that  the  initiative  in  putting  this  dispensary  under  way 
must  come  from  some  privately  organized  group  having  a  special  interest  in 
the  matter.  It  is  recommended  that  shortly  after  the  proposed  Central 
Dispensary  Committee  has  been  organized,  this  committee  initiate  discus- 
sion of  the  matter  and  call  together  a  conference  of  such  individuals  and 
interests  as  may  be  necessary.  Some  one  committee  or  organization  would 
have  to  assume  definite  responsibility  for  the  plant.  This  committee  might 
be  a  joint  body  of  the  organizations  providing  various  services,  or  a  more 
specialized  body  which  made  arrangements  with  the  other  groups  to  use  the 
plant  for  certain  purposes  at  specified  times.  The  plan  will  be  restricted  in 
its  service  in  proportion  as  few  activities  are  included,  and  will  be  broad  and 
far-reaching  as  the  number  of  activities  and  interests  is  increased,  always 
assuming  their  harmonious  coordination.  The  combination  of  the  public- 
health  and  preventive  clinics  with  the  curative  clinics,  for  instance,  is  of 
vital  importance. 

It  would  not  be  unnatural  that  Lakeside  or  Huron  Road,  particularly  if 
their  moving  plans  are  delayed,  should  suggest  that  their  present  dispensary 
be  the  basis  of  the  proposed  central  dispensary.  Such  a  plan  is  not  imprac- 
tical, provided  there  be  sufficient  flexibility  and  readiness  for  cooperative 


Hospitals  and  Dispensaries  925 

adaptation  in  the  existing  organization  which  is  made  the  basis.  It  will  be 
well  to  remember  that  such  a  central  dispensary  represents  a  Health  Center 
in  a  somewhat  advanced  sense  of  the  term;  that  it  might  ideally  contain 
administrative  offices  of  public  and  private  health  agencies,  meeting  rooms 
and  auditoria  for  public  health  education;  and  stand  before  the  people  of 
the  city  as  a  visible  expression  of  the  communal  interest  in  health.  Through 
its  own  activities,  in  which  curative  and  preventive  functions  should  be  cor- 
related, and  through  its  connections  with  the  Central  Dispensary  Committee, 
the  municipal  health  work,  the  business,  educational  and  philanthropic 
interests,  the  proposed  dispensary  might  be  a  constructive  force  as  well  as  a 
service  to  many  individual  lives.  Only  by  grasping  the  possibilities  of  the 
project  in  the  future  can  any  institution  or  any  committee  justify  an  assump- 
tion of  responsibility  for  its  leadership  in  the  present. 


926  Hospital  and  Health  Survey 

IV.      Special  Problems 

THE  CONVALESCENT  AND  THE  HOSPITAL 

By  Mary  Strong  Burns,  R.  N. 

INTRODUCTORY  NOTE 

Mrs.  Burns,  as  a  member  of  the  staff  of  the  Survey,  presents  in  this  chapter  a  study 
of  convalescent  patients  recently  discharged  from  the  hospital.  Few  if  any  cities  have 
as  yet  met  adequately  the  need  for  convalescent  care.  The  most  notable  work  in  the 
country  is  that  of  the  Winifred  Masterson  Burke  Foundation  at  White  Plains,  New  York, 
under  the  direction  of  Dr.  Frederic  Brush,  whose  significant  contribution  as  collaborator 
in  the  Cleveland  Hospital  and  Health  Survey  will  be  found  in  the  next  chapter.  The  bulk 
and  general  bearing  of  the  convalescent  problem  in  Cleveland  is  discussed  in  that  place. 

Mrs.  Burns'  contribution  is  a  series  of  vivid  pictures  of  what  may  happen  to  patients 
after  they  leave  the  hospital  doors,  and  drives  home  the  point  that  a  sick  man's  sojourn 
in  the  hospital  is  only  one  stage  in  the  journey  between  illness  and  health.  Too  easily 
does  the  hospital  forget  this  truth.  Too  often  do  hospitals  in  Cleveland  as  elsewhere 
feel  or  at  least  act  as  though  they  felt  that  their  responsibility  ended  when  "discharged" 
is  written  on  the  record  and  the  patient  is  no  longer  within  the  building. 

The  care  of  convalescents  is  a  much  larger  problem  than  that  of  a  hospital  or  insti- 
tution for  convalescents.  The  bulk  of  convalescence  takes  place  in  the  home,  and  parti- 
ticularly  in  medical  cases,  the  whole  course  of  the  illness,  from  onset  thr^u?h  acute  stage, 
convalescent  stage,  and  final  restoration  to  health  and  vigor,  may  take  place  within  the 
home.  From  this  broader  standpoint  of  the  community,  the  convalescent  problem  is 
approached  in  the  following  chapters. 

In  Mrs.  Burns'  study  emphasis  is  laid  upon  the  hospital  patient  and  his  need  after 
discharge.  Her  very  practical  recommendations  should  be  compared  with  what  has 
been  said  in  the  chapter  on  the  Human  Problem  of  the  Hospital  Patient,  with  reference  to 
hospital  provision  at  the  time  of  discharge  and  the  use  of  the  dispensary  therewith. 

A  STUDY  OF  HOSPITAL   CONVALESCENTS   LN  THEIR,  HOMES 

In  attempting  this  study  two  things  were  very  quickly  apparent:  (1) 
that  convalescence  is  as  much  a  state  of  mind  as  of  body,  and  that  environ- 
ment which  does  not  provide  for  the  needs  of  both  is  inadequate;  (2)  that 
the  background  of  convalescence  is  laid,  the  texture  of  it  stretched  and 
woven,  while  the  patient  is  still  lying  abed  in  hospital.  His  mind  is  a 
sensitive  shuttle  threading  with  tireless  insistence  every  impression  of  the 
hospital  ward,  whether  grave,  radiant,  trivial,  or  profound,  and  coloring 
each  with  his  mood  of  the  moment.  On  the  "date  of  discharge"  (when 
shall  we  find  a  more  gracious  phrase?)  the  patient  takes  this  mental  "sam- 
pler" and  during  the  time  that  he  must  "remain  inactive"  as  the  house 
physician  says,  he  wonders  over  it  all.  If  left  to  himself  he  makes  few 
alterations  in  this  plan  of  return  to  health  which  the  hospital  has  spread 


Hospitals  and  Dispensaries  927 

out  for  his  interpretative  copying.  Every  impression  is  traced  and  retraced 
and  his  conception  of  health  and  of  his  part  in  holding  it  is  framed  in  his 
idea  of  hospital  service  and  remains  pictured  as  a  never-to-be-forgotten 
experience. 

In  seeing  over  two  hundred  such  " pictures' '  one  could  often  exult  that 
the  hospital  had  been  interpreted  favorably  and  with  gratitude.  When  the 
interpretation  had  been  distorted  through  mutual  distrust  and  misunder- 
standing, regret  was  always  followed  by  the  conviction  that  a  broader  con- 
ception of  the  hospital's  responsibility  was  possible,  indeed  necessary,  and 
that  it  would  more  and  more  make  the  way  straight  for  patient  and  hos- 
pital alike.  Two  points  of  view  will  illustrate:  (1)  A  Polish  woman,  after 
three  weeks  in  a  hospital  ward,  thus  voiced  her  opinion  on  the  Hospital 
Bond  Issue,  "She  is  like  a  great  and  wonderful  mother  who  cares  for  many 
sick  children,  this  City  Hospital.  If  more  money  she  needs  let  us  say  yes 
and  give."  (2)  A  man  sensitive  at  being  temporarily  without  money  bitterly 
resented  the  hospital's  attitude  that  he  should  pay  his  bill  there  because  he 
had  hitherto  paid  his  private  doctor,  "Why  would  they  think  I  should  go 
to  that  place  if  I  could  any  longer  pay  a  doctor?  Would  anyone  go  who  did 
not  have  to?     I  burn  with  shame  when  I  think  what  questions  they  ask." 

Thus  convalescence  is  the  state  of  mind  and  body  on  which  the  hos- 
pital may  set  its  stamp  as  a  friend  and  helper  or  as  an  autocrat  without 
sympathy.  The  real  service  to  the  patient  is  but  half  done  on  the  date 
of  discharge.  The  test  then  comes,  to  decide  whether  the  final  stage  of 
convalescence  shall  be  to  each  of  its  patients  a  stimulating,  worth-while 
experience  or  a  lonely  and  difficult  task  to  be  faced  against  great  odds. 

The  cases  studied  were  two  hundred  discharged  patients  from  four  of 
the  principal  hospitals  of  Cleveland:  Charity,  City,  Lakeside,  and  Mount 
Sinai.  They  were  nearly  all  classified  as  free  or  part-pay  patients.  A  few 
had  apparently  paid  the  full  charge  for  treatment.  They  included  a  variety 
of  foreign  nationalities,  of  which  Cleveland  offers  many:  Armenian,  Aus- 
tralian, Bohemian,  Chinese,  Greek,  Italian,  Lithuanian,  Polish,  Slovenian, 
Swedish,  etc.,  a  number  of  native  American  whites  and  a  fair  proportion 
of  Negroes.  The  environment  of  patients  seen  ranged  from  that  of  wretched 
housing  and  extreme  poverty  to  the  completely  comfortable  house  of  the 
well-to-do. 

The  types  of  illness  from  which  these  patients  were  convalescing  were 
contagious  and  general  diseases,  surgical  operations  and  accidents.  There 
were  also  a  few  maternity  cases.  Their  length  of  stay  in  hospital  varied 
from  five  days  to  two  months. 

Half  of  the  cases  were  seen  within  three  to  four  days  after  discharge. 
The  others  were  seen  within  ten  days  after  discharge  with  the  exception 
of  six  surgical  cases  who  had  been  told  not  to  resume  work  for  four  weeks. 

In  the  homes  the  reaction  of  the  hospital  upon  the  patient  was  noted: 
(1)  whether  the  diagnosis  and  medical  advice  had  been  understood,  and  was 
being  followed  with  satisfactory  results;    (2)  whether  assistance  of  any  sort 


928 


Hospital  and  Health  Survey 


would  more  certainly  assure  the  result  for  which  the  hospital  had  worked. 
In  a  word,  was  the  best  sort  of  convalescence  possible  for  that  particular 
patient  in  that  particular  home? 


The  convalescents  seen  were  classified  as  follows: 

Total  Cases  Total  Per  cent. 

12.5 


Cases  with  Home  Environment 

1.  Favorable  and  adequate 

2.  Favorable   with   minor  adjustments,  eco- 

nomic or  personal 

3.  Unfavorable  but  remediable  by  economic 

or  other  assistance _ 

4.  Unfavorable  and  not  remediable,  needing 

institutional  care  in  convalescent  homes 


5.  Acutely  needing  further  hospital  care  — 
relapse  after  return  from  hospital 


25 
71 

48 
44 

12 
200 


35. 5"| 

>59.5   %" 
24.0  J 


22. 


°1 


87.5% 


28. 0%^ 


6.oj 


100.0% 


Thus,  with  only  12.5  per  cent,  in  suroundings  favorable  and  adequate 
for  convalescence,  the  remaining  87.5  per  cent,  of  these  cases  returned  to 
homes  which  were  unfit  in  varying  degrees  for  their  convalescence.  With 
proper  advice  or  assistance,  conditions  could  have  been  remedied  in  about 
two-thirds  of  these  cases  (59.5  per  cent,  of  the  total  number)  while  with  the 
other  third  (28  per  cent,  of  the  total  number)  conditions  were  irremediable 
and  the  patients  required  institutional  care  in  convalescent  homes  or  still 
longer  care  in  hospitals. 


Charity  Hospital 

Considering  the  convalescent  cases  of  each  individual  hospital  as  a 
group,  those  of  Charity  Hospital  presented  the  following  distinctive  char- 
acteristics :                    ' 

Cases  with  Home  Environment                       Total  Cases  Total  Per  cent. 

Favorable  and  adequate _ 15  30.0 

Favorable  with  adjustments „ 21  42.0 

Unfavorable  but  remediable 6  12.0 

Unfavorable  and  not  remediable 6  12.0 

Acutely  needing  further  hospital  care 2  4.0 


50 


100.0% 


As  permission  was  given  to  choose  the  patients  from  the  complete  files 
of  those  discharged  there  were  by  chance  more  pay  or  part-pay  patients 
and  among  these  were  people  of  intelligence  and  personal  capability  who 


Hospitals  and  Dispensaries  929 

had  been  able  to  adjust  their  homes  to  provide  adequately  for  convalescence. 
This  had  sometimes  been  accomplished  by  pre-arrangement,  before  going 
to  the  hospital,  with  some  competent  friend  of  the  family  who  possessed 
the  special  mental  or  moral  force  needed  for  the  situation.  (It  was  notice- 
able that  this  force  was  as  often  absent  in  the  more  prosperous  homes  as 
in  those  of  otherwise  discouraging  surroundings.)  Practically  no  form  of 
social  service  had  been  offered  to  this  prosperous  type  of  patient,  but  the 
patient's  evident  appreciation  of  the  idea  as  a  possibility  was  impressive. 

The  prevalent  feeling  among  the  82  per  cent,  of  operative  cases  among 
women  was  that  they  had  had  the  benefit  of  wonderful  surgery,  but  were 
no  wiser  than  before  the  operation  as  to  what  had  been  the  matter  with 
them  or  what  was  to  be  done  to  prevent  further  difficulty.  The  "head 
doctors"  or  attending  surgeons  were  described  with  awe,  yet  regret,  as 
"too  important  to  be  bothered";  "he's  so  busy  he  can't  listen";  "it  seems 
he's  not  the  kind  of  a  man  to  give  you  much  talk." 

A  gynecological  case  returned  to  her  home  without  instruction  from  the 
hospital,  and  within  two  weeks  had  housecleaned  her  tenement,  painted 
furniture,  papered  two  rooms,  and  was  doing  the  cooking  under  a  sloping 
ceiling  too  low  to  allow  her  to  stand  upright  at  the  stove.  The  doctor  having 
said  she  was  "all  right,"  she  did  not  understand  how  she  felt  worse  than 
before  the  operation.  Concluding  it  was  all  a  failure,  she  had  begun  treat- 
ing herself  with  Lydia  Pinkham's  remedy  because  the  newspapers  said  it 
would  help  anyone  who  felt  as  she  did  and  she  didn't  want  to  waste  any 
more  money  on  the  hospital. 

Another  operative  case  returned  weak  and  wondering  why  the  old  pain 
was  just  as  bad,  while  all  she  "could  get  out  of  the  nurses  and  doctors  was 
that  they  had  gotten  what  caused  the  trouble."  Still  another,  in  a  wretched 
but  pathetically  neat  tenement,  lay  abed,  mystified  at  feeling  worse  than 
ever  before,  while  the  family  questioned  her,  "What  happened?  Have  we 
paid  $86  for  this?"  The  cost  in  money  loomed  larger  than  any  visible 
return  in  health. 

Of  the  women  who  were  uninformed  as  to  their  condition  only  one  had 
not  asked  to  know.     At  seventy  years  she  was  tranquil  and  not  inquisitive. 

The  men  also  had  doubts.  A  neurasthenic,  aggrieved  at  the  little  atten- 
tion bestowed  upon  him  at  the  hospital,  had  gone  home  to  a  combination 
of  quack  electrical  treatments  and  doses  of  No.  99  at  Doctor  Simpson's 
Medical  Institute.  His  protest  was,  "Why  didn't  the  doctor  say  what 
would  do  me  some  good?" 

Another  came  home  to  wretched  lodgings  from  a  long  siege  of  lead- 
poisoning,  pneumonia,  and  an  operation  for  empyema.  While  he  was  ex- 
plaining that  the  incision  had  been  allowed  to  close  too.  soon  because  the 
hospital  was  short  of  beds,  the  doctor  who  had  sent  him  to  Charity  Hos- 
pital came  to  take  him  to  St.  Alexis,  there  being  a  vacant  bed  where  the 
surgeon  who  had  operated  first  would  open  up  the  incision. 


930  Hospital  and  Health  Survey 

A  man,  whose  money  was  low  after  seven  weeks  in  the  hospital,  was 
travelling  a  distance  of  seven  miles  for  dressings  because  he  knew  a  doctor 
who  would  not  charge  much. 

A  sturdy  Irishman '  with  facial  paralysis  after  a  mastoid  operation  was 
embittering  his  days  with  thoughts  of  sueing  the  hospital,  while  his  wife 
wailed,  "Sure,  they  have  destroyed  him  entirely.  'Twould  draw  tears  from 
a  stone." 

The  White  Motor  employes  who  after  leaving  the  hospital  were  cared 
for  at  the  dispensary  of  their  works,  seemed  well  informed  except  in  the 
case  of  one  man.  A  dressing  of  his  foot  had  not  been  changed  for  four 
days.  Having  been  told  that  he  was  "all  right  now,"  he  had  taken  this 
literally,  until  the  pain  and  swelling  led  him  to  doubt.  He  had  recently 
been  burned  out  of  his  home,  and  as  the  only  support  of  a  wife,  mother, 
and  five  children  under  twelve  years,  had  gone  on  a  ten-hour  night  shift 
to  get  the  extra  pay  of  $11.85  a  day.  He  was  slowly  coming  to  the  conclu- 
sion that  his  foot,  by  its  delayed  recovery,  was  costing  more  than  his  hospital 

bill: 

Summary  of  Charity  Hospital  Convalescents — Since  hospital  service 
dominates  convalescence  to  such  a  degree  that  it  has  no  present  but  only  a 
past,  these  cases  have  indicated:  (1)  That  more  nursing  care,  if  only  for  its 
educational  value,  ard  better  night  service,  particularly  for  men,  should  be 
offered.  (2)  That  more  time  should  be  given  to  instructing  all  types  of  pa- 
tients as  to  their  part  in  carrying  on  convalescence,  returning  to  dispensaries 
or  physicians,  etc.    (3)  That  after-care  in  the  homes  is  often  indispensable. 

(4)  That  there  should  be  more  real  interpretation  through  Social  Service  of 
the  problems  of  foreign-born  patients,  so  that  "Tony"  would  not  have  felt  it 
possible  to  get  out  of  bed  and  walk  off  without  saying,  "By  your  leave." 

(5)  That  the  cash  value  of  health  should  be  explained  to  those  patients  who 
reluctantly  offer  their  fees.  With  the  help  of  Social .  Service  every  patient 
should  be  made  proud  to  contribute  his  charity  to  the  common  good. 

City  Hospital 

City  Hospital  presents  the  following  showing: 

Cases  with  Home  Environment  Total  Cases  Total  Per  cent. 

Favorable  and  adequate 5  7.0 

Favorable  with  minor  adjustments 19  26.8 

Unfavorable  but  remediable.. 21  29.6 

Unfavorable  and  not  remediable _ 20  28.2 

Acutely  needing  further  hospital  care 6  8.4 


71  100.0 


The   large    portion    of    those   having  unfavorable  and  irremediable  sur- 
roundings corroborated  the  superintendent's  statement  that  almost  half  of 


Hospitals  and  Dispensaries  931 

their  patients  have  no  homes  and  must  be  kept  in  hospital  until  ready  for 
work,  the  only  alternative  being  the  Warrens vi lie  Infirmary. 

Even  a  superficial  contact  with  the  various  types  of  lodgings,  rooming- 
houses,  and  rooming  hotels,  with  their  forlorn  attempts  at  light  housekeep- 
ing, brings  swift  conviction  that  they  can  never  offer  a  fair  chance  to  con- 
valescents. The  atmosphere  of  isolation,  the  indifference  as  to  what  hap- 
pens to  the  lodger  after  he  pays  for  his  room,  the  long  flights  of  stairs  to  be 
reckoned  with  whenever  a  meal  is  needed — these,  aside  from  the  unwhole- 
some living  conditions,  proclaim  the  lodging  system  as  "fatiguingly  futile" 
for  convalescent  use.  The  patients  themselves  evidently  realize  this  fact 
and  many  did  not  return  to  their  given  address.  Others  had  never  lived  at 
the  given  address,  but  had  been  known  to  the  owner  of  the  lodging  house  or 
to  some  of  the  lodgers.  A  few  gave  an  impossible  street  number  selected 
with  evident  care.  The  Salvation  Army,  the  City  Mission,  a  corner  store, 
or  a  former  saloon  will  sometimes  be  given  as  an  address  where  nothing- 
definite  could  be  remembered  of  the  patient.  One  man  was  found  on  the 
corner  near  the  restaurant  which  he  had  given  as  his  address  and  explained 
there  was  "generally  some  one  round  that  corner  who  knew  where  he  hung 
out."  Such  were  the  frail  links  to  home  and  the  greater  reasons  for  con- 
valescent care  in  institutions  or  at  least  for  continued  hospital  supervision. 

Another  tremendous  claim  for  convalescent  supervision  of  the  most  far- 
reaching  and  efficient  sort  was  made  by  the  fact  that  many  other  patients 
came  from  homes  which  were  totally  unfit  for  convalescence  or  continued 
health,  unfit  for  the  minimum  requirements  of  normal  living — on  the  edge 
of  the  dump,  in  gullies  thick  set  with  smoke,  in  leaky  shacks — the  cracks 
stuffed  with  newspaper  and  the  room  reeking  with  kerosene  fumes,  in  dark 
tenements,  four  or  five  of  which  would  open  on  a  court  filled  with  the  ac- 
cumulated refuse  and  garbage  of  the  winter,  where  the  convalescent  child 
was  left  to  "play. " 

The  hopeful  note  in  many  instances  was  the  persistence  of  the  family  in 
keeping  its  tenement  clean  within  in  spite  of  the  disheartening  mess  without. 

In  several  such  homes  on  Orange  Avenue  there  was  as  keen  an  interest 
and  sense  of  personal  concern  in  the  Survey  of  the  Hospital  Council  as  at  a 
Chamber  of  Commerce  meeting,  thus  bearing  out  the  idea  of  Doctor  Frederic- 
Brush  on  convalescence  that  "health  service  should  be  offered  where  people 
live  and  work  and  play.*  *  *  Of  abiding  value  in  this  period  of  convalescence 
is  the  process  of  normalizing,  in  all  ways  which  may  hold  throughout  life." 

It  is  hard  to  prove  which  will  finally  claim  the  most  patients,  the  influence 
of  the  hospital  or  that  of  the  home  on  the  edge  of  the  dump  beset  by  every 
health  hazard  and  bereft  of  every  help  to  sanitation,  but  it  is  only  when 
Social  Service  shall  present  overwhelming  evidence  of  the  limitation  of  hos- 
pital skill  before  such  handicaps  that  these  entirely  eradicable  conditions  will 
be  swept  away. 

The  surgeon,  who  has  conscientiously  given  his  intelligence  and  skill  to 
renew  life,  should  realize  that  the  condition  of  the  home  to  which  he  is  send- 


932  Hospital  and  Health  Survey 


ing  his  patient,  will  play  a  vital  part  in  the  final  success  of  his  work.  To  have 
a  mind  to  insist  that  dwellings  and  their  surroundings  should  be  fit  for  the 
minimum  requirements  of  ordinary  living  would  be  to  open  up  many  possi- 
bilities in  home  convalescent  care  which,  as  yet,  are  untried,  and  the  import- 
ance of  gain  in  the  general  health  of  the  community  and  in  health  education, 
should  not  be  overlooked. 

Still  other1  types  bespeak  the  follow-up  work  of  the  hospital.  The  drug 
addict,  returning  to  lodgings  with  little  moral  support;  the  child  with  chorea 
celebrating  her  home-coming  with  a  "regular  meal"  of  coffee,  sausage  and 
pie;  the  heart  case  who  has  spent  most  of  his  small  life  in  hospitals  and 
pleaded,  "Oh,  Muz,  my  business  is  always  hospitals!  Can't  I  stay  home 
and  get  well?";  the  fourteen-year-old  runaway  with  mumps  whose  pride 
had  thus  resented  his  being  put  in  the  "kids'  ward"  where  his  feet  stuck  out 
through  the  bed-bars;  the  child  of  five  whose  mother  had  never  been  able 
to  find  out  from  the  hospital  what  its  illness  had  been — these  and  many 
others  proclaimed  their  necessity  for  further  care  without  which  a  large  part 
of  the  hospital's  work  goes  for  naught. 

Summary  of  City  Hospital  Convalescents — These  cases  present  the 
following  well-defined  needs:  (1)  Increased  institutional  convalescent  care; 
(2)  Instruction  of  patient  at  discharge;  (3)  Social  Service,  to  adapt  the  homes 
of  patients  for  convalescence  therein. 

Lakeside  Hospital 

Lakeside  Hospital  showed: 

Cases  with  Home  Environment 

Favorable  and  adequate 

Favorable  with  minor  adjustments 

Unfavorable  but  remediable 

Unfavorable  and  not  remediable 

Acutely  needing  further  hospital  care._ 

57  100.0 

The  cases  were  offered  with  ample  records  and  in  the  spirit  of  the  fullest 
cooperation.  Probably  because  of  this  it  was  more  noticeable  that  the 
instructions  to  patients  by  the  doctor  were  most  often  "none  in  particular" 
or  "return  to  dispensary." 

The  "none  in  particular"  probably  indicated  that  to  the  doctor  the  case 
did  not  stand  out  in  his  mind  as  needing  any  instructions  other  than  those  of 
routine  convalescent  care  after  a  pneumonia,  a  laparotomy,  or  whatever 
else  the  disease  or  operation  might  be.  The  patient,  however,  assuming 
this  role  for  the  first  time, finds  everything  strange  about  being  "a  pneumonia" 
and  things  stranger  still  as  "a  laparotomy. "  He  is  full  of  interest  in  himself. 
He  wants  to  make  a  success  of  getting  well  and  there  are  many  questions  to 


Total  Cases 

Total  Per  cent. 

4 

7.0 

21 

36.8 

14 

24.6 

16 

28.1 

2 

3.5 

Hospitals  and  Dispensaries  933 

which  he  wants  to  know  the  answers.  He  is  hoping  there  will  be  time  for 
one  of  the  doctors  to  have  a  talk  with  him  about  it  all  before  he  leaves  the 
hospital.  But  often  the  last  day  comes  unexpectedly,  his  bed  being  needed 
for  a  more  urgent  case,  and  he  finds  himself  at  home  several  miles  from  the 
hospital,  wondering  why  he  managed  to  find  out  so  little  of  what  the  hos- 
pital knew  so  well.  When  special  instruction  had  been  given  the  patient 
on  discharge,  the  effect  was  almost  magical.  To  have  been  instructed  to  carry 
on  what  the  nurses  have  begun,  to  have  responsibility  for  one's  own  treat- 
ment, gave  a  new  zest  and  importance  to  convalescence.  Particularly  was 
this  noticeable  in  patients  who  were  returned  to  the  dispensary  for  the  treat- 
ment of  syphilis.  Alert  and  intelligent,  they  were  too  much  in  earnest  to 
be  self-conscious  and  presented  convincing  evidence  of  wise  and  inspired 
teaching.  With  the  exception  of  these  cases  there  was  little  evidence  of  hos- 
pital Social  Service  other  than  visiting  nursing  among  the  patients  seen  from 
Lakeside. 

The  ambulance  experiences  of  many  held  a  large  share  in  their  convales- 
cent thoughts.  The  negro  who,  after  an  automobile  accident,  regained 
consciousness  in  "Hogan's  dead  wagon,"  "don't  never  expect  to  get  over 
that  wake  up. "  He  thought  he  was  being  taken  to  the  undertaker's  estab- 
lishment as  dead.  Often  neighbors  have  "chipped  in"  to  collect  the  money 
for  an  invalid  carriage  so  that  the  police  emergency  need  not  be  called,  and 
with  a  naive  idea  of  gradual  descent  to  the  mundane,  some  announced  that 
in  leaving  the  hospital,  they  took  a  taxi  to  the  nearest  car-line  and  transferred 
to  the  trolley  for  the  rest  of  the  way  home. 

Another  impression  noted  among  the  women  was  remembering  the  fa- 
tigue of  that  first  complete  dressing  to  leave  the  hospital.  Apparently  this 
was  often  done  without  assistance  as  the  nurses  had  other  duties  and  the 
friends  of  the  patient  were  not  allowed  to  come  to  the  ward.  (This  was  also 
noted  in  patients  from  other  hospitals.  An  old  negro  woman  with  an  aortic 
aneurism  was  being  sent  home  from  the  City  Hospital  on  the  ambulance 
stretcher.  She  described  the  fatigue  of  preparation  and  added  "The  head 
lady  nurse  told  them,  'Don't  bother  if  it  is  a  hospital  gown — let  her  go  while 
the  spirit  is  in  her.'  I  sure  was  grateful.  She  certainly  had  wisdom,  that 
lady  nurse. ") 

Two  other  shadows  of  convalescence  were:  (1)  the  long  uncertainty  and 
final  disappointment  over  the  amount  of  the  hospital  bill,  and  (2)  the  fact 
that  patients  sometimes  came  away  resentful  because  they  had  been  the 
"interesting  case"  used  to  teach  others.  They  felt  that  they  were  being 
detained  in  hospital  for  this  purpose. 

These  may  seem  minor  details  in  the  immense  and  complex  scheme  of 
administration  which  the  hospital  must  embrace,  but  with  the  sensitive 
imagination  of  one  half  sick — "behold,  a  little  cloud  ariseth"  and  the  whole 
of  his  convalescent  sky  is  darkened. 

The  amount  of  the  bill  could  be  approximately  decided  before  the  day  of 
discharge  and  preferably  nearer  the  day  of  admission  so  that  this  "indeter- 
minate sentence"  might  be  cleared  up.     If  the  patient  has  not  been  able  to 


934  Hospital  and  Health  Subvey 

pay,  it  is  perhaps  not  the  happiest  sort  of  envoi  to  haYe  "the  last  one  you 
see  at  the  front  door  saying,  'I  hope  you  will  be  able  to  work  soon  and  pay  your 
bill.'  '  Social  serYice  at  the  front  door  might  perhaps  have  given  the  deft 
touch  to  incentive  which  would  have  brought  the  patient  to  say  as  much  for 
himself,  with  gratitude  and  courage. 

Again,  in  the  matter  of  the  resentful  "interesting  case"  the  house  phy- 
sician who  is  a  vital  influence  for  energizing  convalescence,  could  in  a  few 
words,  with  perhaps  a  touch  of  cameraderie,  present  the  idea  of  an  imper- 
sonal yet  chivalrous  appeal  for  humanity,  and  the  patient  might  become  at 
once  the  "interested  case,"  ready  and  a  little  grateful  to  contribute  to  the 
advancement  of  clinical  medicine  and  scientific  research. 

The  foreign-born  patients  who  had  had  bedside  lessons  in  English  in 
the  hospital  and  who  had  heard  their  own  language  understood  and  trans- 
lated by  a  sympathetic  interpreter,  beamed  with  appreciation  at  the  re- 
membrance. This  happy  cooperation  with  the  Board  of  Education  can  be 
developed  so  that  the  often  empty  hours  of  convalescence  will  be  brimming 
with  interest. 

Summary  of  Lakeside  Hospital  Convalescents — Almost  without  ex- 
ception the  Lakeside  cases  showed  that  the  completion  of  the  hospital's 
work  can  only  be  accomplished  outside  of  the  hospital  and  through  the  ex- 
tension service  of  social  work. 

Whether  this  is  rendered  in  the  guise  of  institutional  convalescent  care 
or  of  home  service,  there  is  every  indication  that  the  expense  would  be  less 
than  a  protracted  stay  in  the  hospital.  The  patients  are  quick  to  testify 
that  after  the  first  urgent  need  of  acute  illness  the  hospital  atmosphere  is 
not  helpful.     Its  ceaseless  movement  is  too  intense  and  vivid  for  rest. 

To  the  patient  with  a  problem  waiting  at  home,  institutional  convales- 
cence, however  luxurious,  has  little  charm — "For  what  good  should  I  go 
away.  The  worry  for  the  kids  would  go  with  me,"  said  a  mother  amid  a 
clutter  of  babies,  washtubs  and  general  disorder.  "This  is  the  best  for  me 
here."  Her  peace  of  mind  arose  triumphant  over  the  scene  of  distraction, 
for  her  problem  was  within  her  grasp. 

The  unanimous  opinion  among  such  convalescents  was  that  any  help  in 
household  administration  would  be  welcomed. 


Mt.   Sinai  Hospital 

The  cases  referred  from  Mt  Sinai  came  to  the  investigator  slowly  and 
were  possibly  a  more  or  Jess  expurgated  edition,  as  there  seemed  some  appre- 
hension lest  the  hospital's  social  work  should  be  duplicated.  Maternity 
cases  were  excluded.  For  this  reason  the  number  of  cases  for  consideration 
was  smaller  than  from  the  other  hospitals,  only  thirty-five  being  offered.    Of 


Hospitals  and  Dispensaries  935 

these  thirteen  were  not  seen,  leaving  the  following  percentage  compiled  on  a 
basis  of  the  twenty -two  cases  seen: 

Cases  with  Home  Environment 

Favorable  and  adequate _ 

Favorable  with  minor  adjustments 

Unfavorable  but  remediable 

Unfavorable  and  not  remediable 

Acutely  needing  further  hospital  care 


Total  Cases 

Total  Per  cent 

1 

4.5 

10 

45.5 

7 

31.8 

2 

9.1 

2 

9.1 

22  100.0 

One  characteristic  of  this  group  as  a  whole  was  that  the  patients  seemed 
to  have  achieved  a  definite  idea  of  the  hospital's  plan  for  them  and  their 
repeated  trips  to  the  dispensary  were  playing  an  important  part  in  their 
convalescence.  The  majority  were  looking  upon  the  situation  as  a  business 
proposition  without  imagination.  The  evident  system  and  efficient  working 
of  the  ward  routine  had  impressed  them  and  they  were  ready  to  do  what 
was  required.  They  seemed  less  susceptible  to  untoward  surroundings  at 
home  because  of  the  definite  goal  toward  which  they  were  working.  Pos- 
sibly this  unanimity  may  have  been  more  evident  because  of  the  smaller 
number,  but  it  was  too  marked  to  escape  notice. 

The  Collected  Groups 

Among  the  patients  of  all  four  groups  were  some  who  had  been  treated  at 
two  or  more  different  hospitals  for  the  same  or  different  causes — the  patient, 
not  having  mentioned  this  in  giving  her  medical  history  at  the  hospital  be- 
cause she  did  not  know,  or  "was  not  sure  how  to  tell  it,"  and  thought  "the 
next  doctor  would  find  out. "  In  large  families  the  hospital  affiliation  was 
widespread,  several  hospitals  having  been  used  by  three  or  four  members, 
and  experience  meetings  when  all  talked  at  once  brought  out  a  variety  of 
hospital  lights  and  shades.  This  suggested  the  possibility  of  extending  the 
scope  of  the  Social  Service  Clearing  House  to  include  on  its  registry  cards  a 
note  of  any  dispensary  or  hospital  care  which  the  patient  had  received — the 
technical  details  to  be  furnished  by  each  medical  agency  as  the  occasion 
arose,  as  the  patient  is  often  unable  to  give  an  accurate  account  of  past 
illness  or  surgical  operations. 

The  very  prevalent  protest  of  the  women  patients  against  being  kept  in 
ignorance  of  the  nature  of  their  surgical  operations  deserves  a  word.  The 
patient  wants  to  know  how  she  stands  physically,  even  if  she  faces  a  serious 
handicap,  and  she  can  the  better  adjust  herself  to  meet  it  if  informed.  The 
hospital  service  which  shirks,  evades,  or  refuses  this  after-treatment  so  neces- 
sary to  the  peace  of  mind  and  progress  of  convalescence  has  put  the  hardest 
part  of  the  operation  and  its  results  on  the  patient,  and  has  missed  its  best 
chance  of  rehabilitation. 

Why  bother  at  all  if  the  game  is  not  worth  the  candle — if  the  work  is  not 
to  be  carried  through  to  completion  and  the  seal  set  upon  restored  health 


936  Hospital  and  Health  Survey 

and  higher  spirit?  If  the  patient  is  well  enough  to  worry  herself  about  her 
condition  she  is  well  enough  to  know  what  she  has  to  worry  about.  She  will 
then  be  more  willing  to  put  aside  imaginings  and  prepare  to  recuperate  in 
earnest. 

Those  who  have  had  the  fertile  experience  of  a  perfect  convalescence 
have  realized  that  there  is  much  to  be  learned  from  contact  with  pain  and 
weakness  and  returning  strength.  The  convalescent  patient  should  be 
helped  to  find  these  values,  to  lay  aside  a  few  worries  and  to  take  on  a  few 
new  aspirations  for  the  future.  Inspiriting  companionship  may  often  be 
found  in  one's  nearest  neighbor  with  a  wholesome  philosophy  to  share. 

In  becoming  acquainted  with  the  convalescent  in  his  own  home  we  must 
let  him  state  the  difficulty  of  convalescence  as  he  sees  it,  along  with  his  own 
idea  of  rehabilitation  before  blocking  the  way  with  too  many  suggestions. 

Often  the  patient  must  either  resign  himself  to  a  reduced  "health  bank 
account"  or  remonstrate  at  untoward  conditions;  again,  the  uncertainty  as 
to  what  his  depleted  strength  is  equal  to,  makes  any  definite  undertaking 
precarious.  This  is  no  time  for  platitudes  in  words  or  actions.  No  "re- 
turn to  dispensary"  slip  will  fill  the  need.  Advice  to  "rest  and  take  it 
easy"  will  not  answer.  Reinstatement  into  the  type  of  life  to  which  the 
patient  is  equal  must  be  wisely  planned  and  the  very  present  helps  of  com- 
munity life  pressed  into  service,  so  that  the  thrill  of  ambition,  the  impetus 
to  new  life  which  rightfully  belong  to  convalescence  may  not  be  entirely 
lost. 


SUMMARY 

Visits  to  two  hundred  patients  discharged  from  the  wards  of  Cleveland 
hospitals  showed  eighty-seven  and  one-half  per  cent,  in  home  environment 
unfavorable  for  convalescence. 

In  two-thirds  of  these  homes,  conditions  were  remediable  if  adequate 
and  adaptable  Social  Service  could  be  supplied.  This  service  is  almost 
entirely  lacking  at  present. 

In  one-third,  conditions  were  not  remediable,  and  care  in  a  convalescent 
home  was  needed.  With  present  resources  it  is  impossible  to  meet  this  need. 
The  hospital  faces  a  choice  of  evils — it  must  either  retain  the  patient,  using  a 
bed  needed  for  a  case  of  acute  illness,  or  return  the  patient  to  a  home  un- 
fitted to  complete  the  cure. 

Possible  means  by  which  the  hospital  may  assist  convalescence  in  the 
home: 

1.  Treatment  and  instruction  in  hospital  towards  securing  the  patient's 
confidence  and  cooperation — the  instruction  to  include  understanding  of 
present  illness  and  means  of  preventing  recurrence. 

2.  Making  with  the  patient  a  definite  plan  for  his  after-care  and  rein- 
statement into  active  life,  and  enlisting  his  best  effort  to  carry  out  such  a  plan. 


Hospitals  and  Dispensaries  937 

3.  The  function  of  the  Social  Service  Clearing  House  might  be  broad- 
ened so  as  to  include  a  record  of  dispensary  and  hospital  treatment  received 
by  the  patient,  with  names  of  institutions  and  dates.  This  record  could 
be  used  by  medical  agencies  concerned  as  occasion  requires. 

4.  The  function  and  value  of  the  Convalescent  Home,  when  suitable 
and  available,  should  be  explained  to  the  patient  as  an  opportunity. 

5.  Social  Service  (if  a  Convalescent  Home  is  not  available  or  desirable) 
should  create  the  same  essential  values  of  convalescence  in  the  patient's 
own  home. 

6.  Teaching  the  patient  while  most  receptive  to  suggestions — because 
of  recent  contact  with  the  hospital  technic  of  sanitation — how  he  may  fur- 
ther the  hospital's  work  to  insure  permanent  good  health.  This  would 
include  the"  use  of  dispensary  and  other  hospital  resources,  as  well  as  of  the 
family  physician. 

A  patient  thus  successfuly  involved  becomes  a  valuable  field  agent  who 
will  set  forth  the  work  of  the  hospital  in  terms  of  appreciation  which  his 
neighborhood  will  not  fail  to  understand. 


938  Hospital  and  Health  Survey 


A  COMMUNITY  PROGRAM  FOR  CONVALESCENT  CARE 

An  institution  is  not  the  ideal  place  for  convalescence  from  disease.  The 
home,  when  conditions  are  satisfactory,  is  the  ideal  place.  The  possibilities 
of  home  convalescence  are  only  beginning  to  be  dealt  with.  In  the  pre- 
ceding chapter  home  convalescence  was  touched  upon  in  relation  to  the  hos- 
pitals, with  reference  to  planning  the  after-care  for  the  patient,  instructing 
him  or  his  family  properly  at  the  time  of  discharge,  using  the  dispensary  to 
provide  medical  after-care,  and  social  service.  The  last-named  function 
served  either  by  the  social  service  department  of  the  hospital,  or  by  cooperat- 
ing agencies  such  as  the  Visiting  Nurse  Association  or  the  Associated  Chari- 
ties, is  a  necessity.  It  should  further  be  borne  in  mind  that  the  aid  of  social 
service  is  not  called  for  merely  in  homes  of  poverty.  Much  work  needs  to 
be  done  in  middle  class  homes  by  the  Visiting  Nurse  Association  or  by  a 
representative  of  the  social  service  department  to  give  the  necessary  instruc- 
tion and  friendly  advice  about  the  details  of  home  management,  diet,  hy- 
giene, etc.,  without  which  the  family  will  usually  not  carry  out  the  necessary 
routine  outlined  by  the  physician.  Cooperation  with  the  employer  or  the 
industrial  physician,  is  not  infrequently  of  great  importance.  The  vast  num- 
ber of  medical  cases  which  are  cared  for  in  their  homes  by  private  phy- 
sicians, and  which  convalesce  at  home  need  such  advice  no  less  than  do 
hospital  cases. 

In  a  word,  the  broad  problem  of  convalescence  involves  private  medical 
practice,  the  hospital,  the  dispensary,  the  Visiting  Nurse  Association,  and 
social  service  in  many  branches.  Many  individuals  and  many  agencies 
must  share  in  creating  better  opportunities  for  both  home  and  institutional 
convalescence  than  now  exist  in  Cleveland.  An  essential  element  to  any 
real  advance  is  an  adequately  maintained  convalescent  institution.  Such  an 
institution  does  much  more  than  provide  care  for  the  particular  patients 
who  can  be  admitted  to  it.  It  would  serve  to  stimulate  medical  study  of 
convalescence,  now  a  field  much  neglected,  and  would  promote  throughout 
the  community,  interest  in  the  problem  of  convalescence  which  will  add  to 
the  efficiency  of  all  kinds  of  medical  care  in  hospitals,  dispensaries  and  in 
the  home. 

For  an  authoritative  picture  of  the  need  for  convalescent  care  in  a  com- 
munity such  as  Cleveland,  and  a  program  for  a  central  representative  in- 
stitution for  convalescents,  the  Survey  turned  to  Dr.  Frederic  Brush,  Medical 
Director  of  the  Burke  Foundation  at  White  Plains,  New  York,  the  leading 
institution  in  the  United  States  for  the  efficient  treatment  and  scientific 
study  of  convalescence.  The  following  memorandum  was  prepared  by 
Doctor  Brush: 

CONVALESCENT  CARE 

For  an  American  City  of  One  Million  Population 

1  By  Frederic  Brush,  M.  D. 

The  Need 

There  is  a  convalescent  period  in  illness,  with  fairly  distinct  medical  and 
social  borders,  and  now  recognized  as  a  particularly  favorable  time  for  skilled 


Hospitals  and  Dispensaries  939 

aid  in  rehabilitation.  The  patient's  home  is  the  desired,  the  cheapest,  and 
best  place  for  most  convalescence,  but  institutional  convalescence  is  needed 
for  a  certain  percentage,  in  large  cities. 

Such  an  institution  in  its  modern  conception  functions  widely  beyond  mere 
recuperative  rest — in  prevention,  education,  refinement,  and  Americaniza- 
tion, occupational  adjustment,  vocational  direction,  encouragement,  and  all- 
round  set-up  for  better  living.  It  complements  home  care,  and  notably 
completes  and  fortifies  social  service.  It  shortens  the  hospital  stay,  with 
large  increase  of  product,  and  with  inspiration  to  the  staff.  It  saves  money 
directly  (convalescent  cost  being  but  little  over  one-half  hospital  cost  per 
day,)  and  makes  large  long  term  returns  to  the  community  in  bettered  per- 
sonnel. 


Numbers  Needing  Country  Convalescence 

Various  estimates  have  been  attempted  based  upon  the  number  of  hospital 
patients  in  the  community,  plus  a  small  percentage  from  dispensaries,  pri- 
vate physicians,  employers,  etc.  These  may  be  summarized  into  an  ideal 
requirement  of  convalescent  beds  for  ten  per  cent,  of  all  hospital  patients — 
varying  greatly,  of  course,  depending  upon  each  city's  conditions.  To  this 
should  be  added  about  one-fifth  for  dispensaries  and  other  sources  (as  at 
present  organized;  but  this  ratio  should  be  increased).  Thus  a  city  discharg- 
ing 100,000  hospital  patients  yearly  should  provide  institutional  care  for 
12,000  convalescents. 

Number  of  Beds  and  Apportionment  of  Patients 

Assuming  that  the  city  in  question  presents  the  better  living  conditions, 
we'may  well  take  5,000  hospital  patients,  plus  1,000  from  other  sources,  as 
a  planning  basis.  About  twenty-one  days  proves  to  be  the  average  stay  in 
convalescent  homes.  The  requirement  for  the  6,000  patients  is  accordinglv 
350  beds. 

We  may  base  an  estimate  upon  the  long  and  abundant  experiences  in 
our  greater  cities,  and  apportion  them  as  follows: 

1.  The  Main  Institution,  for  adults — 120  beds;  men  and  women — ages, 
from  fifteenth  birthday  upwards  to  old  age,  including  15  per  cent,  plus  of 
heart  disease,  with  standard  surgical  (with  dressings),  pi~ventive  and  hold- 
ing (chronic  handicapped)  convalescence. 

2.  Children's  Home — 100  beds,  taking  girls  from  6  to  15  and  boys 
from  6  to  10  years,  receiving  surgical  dressing  and  orthopedic  cases,  and 
heart  disease  up  to  20  per  cent,  of  total,  along  with  the  standard  lines  as 
above  outlined. 

3.  Boys'  Place — 30  beds,  ages  10  to  15;  disease  classification  as  in  the 
Children's  Home    (Very  important  but  not  to  be  large). 


940  Hospital  and  Health  Survey 


4.  Mothers  with  infants  and  young  children — 30  beds,   averaging    60 
patients. 

5.  Special  Heart  Institution — 40  beds,  for  the  seriously  ill,  giving  bed 
care  at  first,  etc.     Age  and  sex  as  in  Number  2. 


The  Plants 


i 


New  or  expensive  buildings  are  not  essential.  An  old  mansion,  a  large 
farmhouse  with  its  many  outbuildings,  or  a  disused  hotel  adapt  readily. 
Tents  serve  well  at  times;  extensions  are  happily  made;  much  equipment 
may  be  improvised.  Five  acres  of  land  is  minimum;  the  larger  areas  giving 
considerable  advantages.  These  Homes  might  be  conducted  upon  one 
large  plot  of  100  acres  if  the  topography,  etc.,  gave  essential  separation  of 
patient's  activities.  A  location  well  within  20  miles  of  the  city's  center  should 
be  chosen,  if  possible. 

Costs 

W  A  per  day  capita  cost  of  $1.75  may  be  expected,  even  under  post-war 
conditions,  giving  $225,000.00  yearly  operating  expense  for  the  350  beds,  as 
approximate.  This  includes  transportation,  and  maintenance  of  a  City 
Admission  Office. 

Selection  of  Patients,  Follow-up,  etc. 

Careful  selection  of  patients  by  one  City  Officer,  given  authority  and 
support,  is  of  first  importance.  This  officer  may  be  on  part-time  only.  The 
necessary  follow-up,  including  occupational  and  vocational  direction,  is 
usually  well  done  by  the  city  organization  which  sends  patients,  and  the  back- 
to-health-and-to-normal-life  cycle  is  only  thus  completed. 

Convalescent  home  planning,  organization,  and  procedure  are  becoming 
fairly  well  standardized,  with  detailed  information  readily  available. 


Those  of  the  Staff  of  the  Survey  who  have  been  engaged  in  the  local 
study  of  convalescent  institutions  and  the  convalescent  problem  can  only 
add  to  Doctor  Brush's  statement  some  suggestions  relating  his  program  more 
in  detail  to  present  conditions  and  probable  future  development  in  Cleve- 
land. 

In  most  cities  the  convalescent  problem,  so  far  as  it  has  been  dealt  with, 
has  been  taken  up  by  bits  and  snatches.  Here  a  group  of  kindly  people 
have  taken  a  large  dwelling  house  and  made  it  into  a  "convalescent  home" 
for  some  twenty -five  men;  another  committee  of  the  charitable  maintain  a 
building  donated  by  one  of  their  number,  in  which  sickly  and  tired  mothers 
may  recuperate  after  illness  or  operation;  still  another  group  has  under  its 
wing  a  small  institution  for  children;  and  yet  another  a  small  "preventorium" 
for  the  pre-tuberculous  child. 


Hospitals  and  Dispensaries  941 

One  of  the  great  lessons  which  the  Burke  Foundation  has  taught  is  the 
greater  efficiency  gained  through  the  use  of  a  large  institution  instead  of  a 
number  of  little  ones.  The  small  independently  managed  convalescent 
home,  accepting  ten  to  fifty  patients,  secures  with  difficulty  expert  medical 
service  of  physicians  who  are  particularly  interested  in  the  convalescent 
problem  and  scientific  study  of  convalescent  cases;  it  cannot  possibly  pro- 
vide elaborate  therapeutic  equipment  or  a  staff  of  special  workers  and  teachers. 
In  the  large  institution,  therapeutic  equipment,  personnel  and  continuous 
service  of  a  medical  staff  whose  members  are  selected  especially  because 
they  are  interested  in  convalescence  are  all  possible  within  reasonable  limits 
of  expense. 

In  a  letter  transmitting  his  outline,  Doctor  Brush  remarks:  "It  may  be 
well  to  bring  to  the  attention  of  those  becoming  interested  in  this  branch, 
some  of  the  important  points  of  this  proposal:  that  preventative  tubercu- 
culosis  comes  in  under  numbers  1,  2,  and  3;  convalescent  orthopedics,  bone 
diseases,  etc.,  likewise  in  these  three  places;  that  cardiac  children  well  enough 
for  reconstructive  treatment  enter  under  numbers  2  and  3;  that  adolescents 
(the  group  most  successfully  dealt  with  and  most  neglected  in  convales- 
cence) are  especially  well  planned  for.     *     *     * 

"Perhaps  the  most  characteristic  and  radical  part  of  my  conclusions  is 
the  recommendation,  based  upon  definite  experience,  for  the  care  of  many 
different  classes  and  ages,  etc.,  in  one  Institution  (see  numbers  1  and  2.)" 

The  recommendation  to  be  made  regarding  the  convalescent  problem  of 
Cleveland  is  that  it  be  dealt  with  not  by  bits  and  snatches,  but  by  one  central 
and  representative  group  of  persons  who  will  study  the  whole  problem  and, 
with  a  long  range  program  in  mind,  will  take  each  practical  step  as  funds 
are  made  available.  So  far  as  institutions  are  concerned,  there  should  be  one, 
rather  than  many,  or  rather,  as  Doctor  Brush's  outline  indicates,  a  group 
of  related  institutions  managed  as  one. 

At  present  Cleveland  has : 

Rainbow  Hospital,  with  85  beds,  taking  children  between  2}/<i  and 
14  years  of  age,  mostly  orthopedic  cases. 

The  Children's  Fresh   Air   Camp,   with  60  beds  (225  in  summer), 
receiving  weak,  anaemic  children  and  some  convalescent  mothers. 

Holy  Cross  House,  with  a  capacity  of  50  beds,  receiving  crippled  and 
invalid  children  (chronic  rather  than  convalescent  cases). 

For  adults  a  small  number  of  chronic  cases  are  held  at  City  Hospital, 
but  no  convalescent  cases  are  supposed  to  be  there.  At  Warrens ville  In- 
firmary are  numbers  of  chronic  and  incurable  cases,  but  little  provision  for 
convalescents.  In  a  few  of  the  private  institutions  of  the  proprietary  type 
convalescent  cases  are  treated,  but  the  number  of  beds  available  for  such  is 
very  small. 


942  Hospital  and  Health  Survey 

Taken  as  a  whole,  institutional  provision  for  convalescents  in  Cleveland 
is  practically  confined  to  children,  and  even  for  them  is  limited  to  certain 
types  of  cases.  The  main  resources  throughout  the  year  are  Rainbow  Hos- 
pital, and  in  summer  time,  the  Children's  Fresh  Air  Camp. 

The  major  need  is  that  some  one  central  and  representative  group  should 
assume  the  responsibility  of  developing  convalescent  provisions  which  will 
be  adequatcfor  the  needs  of  the  city.  It  is  recommended  that  the  Trustees 
of  Rainbow  Hospital  either  assume  this  responsibility,  or  at  least  act  as  the 
agent  through  which  some  larger  group  might  ultimately  be  organized. 
Rainbow  Hospital  now  provides  an  excellent  service  to  a  limited  range  of 
patients,  but  appears  to  furnish  a  basis  upon  which  a  much  more  compre- 
hensive and  satisfactory  development  might  be  made. 

With  this  in  view,  it  is  desirable  that  Rainbow  Hospital  should  enlarge 
immediately  the  scope  of  its  work.  It  should  have  no  exclusive  affiliation 
with  any  one  hospital  with  respect  to  its  medical  staff  or  t  with  respect  to  the 
reception  of  patients.  It  should  aim  to  develop  a  staff  which  is  especially 
interested  in  the  scientific  medical  study  of  convalescence.  It  should  at 
once  undertake  to  receive  a,  considerable  group  of  cardiac  cases  from  the  chil- 
dren's services  of  the  Cleveland  hospitals,  as  well  as  convalescent  orthopedic 
and  surgical  cases.  It  should  institute  studies  of  the  convalescent  problem 
in  Cleveland,  supplementing  those  made  by  the  Survey,  and  through  its 
members  or  representatives  the  Board  should  study  notable  developments 
in  other  cities,  particularly  the  Burke  Foundation,  as  a  basis  for  the  formu- 
lation of  a  program  and  of  the  definite  steps  which  should  be  taken  year 
by  year  towards  its  execution.  Publication  of  these  studies  and  reports  of 
the  case  work  with  convalescents  of  various  types  are  important  phases  of 
such  a  program,  and  are  essential  to  the  growth  of  appreciation  of  the  con- 
valescent problem  by  the  medical  profession  and  the  public.  Cooperative 
affiliation  with  related  agencies,  such  as  some  of  those  above  mentioned, 
would  be  desirable  in  the  formulation  and  execution  of  any  such  program. 

Provision  of  a  convalescent  institution  for  adults,  should  be  made  as  soon 
as  possible,  as  a  part  of  this  plan,  either  by  Rainbow  Hospital  or  by  a  group 
of  persons  organized  in  cooperation  therewith. 

The  outline  presented  by  Doctor  Brush  gives  a  program  which  for  finan- 
cial reasons  alone  cannot  be  realized  in  a  day,  yet  nothing  less  than  this 
should Jbe  accepted  as  worthy  of  a  progressive  city. 

The  cost  of  maintenance  of  a  convalescent  institution  is  about  half  that 
of  a  hospital  receiving  the  same  number  of  persons  with  acute  diseases.  A 
convalescent  home  is  an  institution  which  no  city  can  afford  to  omit  in 
providing  for  its  sick.  Its  absence  means  burdens  upon  the  hospitals,  which 
involve  undue  expense,  and  burdens  upon  the  community  which  are  less 
easily  traced,  but  which  are  no  less  real,  being  a  financial  drain  upon  the 
charitable  public  and  a  definite  loss  to  wage  earners  and  to  employing  in- 
terests. 

When  serious  illness  befalls,  the  care  of  the  patient  in  home  or  hospital 
equires,  as  it  were,  an  investment  on  the  part  of  the  community  in  order 


Hospitals  and  Dispensaries  943 

that  the  sick  man  shall  be  restored  to  health  and  living  efficiency.  From 
the  financial  as  well  as  from  the  humanitarian  standpoint  it  is  to  the  com- 
munity's interest  that  this  restoration  shall  be  complete  and  shall  be  as 
prompt  as  possible.  A  period  of  stay  in  a  hospital  for  acute  diseases  repre- 
sents a  part,  often  the  most  expensive  part  of  the  investment,  but  the  subse- 
quent period  of  convalescence,  either  at  home  or  in  an  institution,  requires  a 
certain  investment  of  time,  skill,  and  money,  also.  Unless  this  subsidiary 
but  important  investment  in  convalescence  is  made,  the  value  of  the  whole 
investment  may  be  nil.  It  is  difficult  to  put  such  an  argument  in  financial 
terms  of  actual  cases,  but  it  should  not  be  difficult  to  appreciate  the  tragedy 
and  the  waste  of  insufficient  convalescence,  and  to  strike  the  imagination  of 
citizens  of  Cleveland  who  have  the  means,  to  support  a  program  and  develop 
an  institution  which  shall  be  worthy  of  their  city. 


944  Hospital  and  Health  Survey 


CHRONIC  ILLNESS  AND  ITS  CARE 

Through  the  courtesy  of  the  Visiting  Nurse  Association  and  the  Division 
of  Health,  a  list  was  secured  by  the  Survey  of  all  patients  who  were  treated 
in  their  homes  during  the  month  of  November,  1919,  by  the  nurses  of  these 
organizations,  who  were  regarded  as  chronic,  incurable  or  convalescent 
cases.  A  list  of  2,078  persons  was  furnished.  In  the  absence  of  an  oppor- 
tunity to  make  intimate  medical  study  of  each  case,  it  was  not  possible  to 
draw  a  sharp  line  between  the  chronic  and  the  convalescent,  but  only  about 
ten  per  cent,  were  believed  to  be  of  the  convalescent  class.  The  remaining 
cases,  some  1,800  in  number,  were  chiefly  people  suffering  from  chronic 
disorders,  living  at  home,  but  needing  more  or  less  regular  nursing  or  medical 
attention. 

A  tabulation  of  these  cases,  classified  by  age  and  groups  of  diseases  is 
given  in  the  following  table: 

.  Chronic  and  Convalescent  Cases  Under  Nursing  Care 

Diagnoses  Cases 

General _ 142 

Respiratory  (except  tuberculosis) _ 63 

Circulatory „ 37 

Digestive 127 

Nervous  System 1 74 

Mental 17 


Total  (not  including  tuberculosis) 560 

Tuberculosis 1 ,  518 


Grand  Total 2  ,078 


Total  cases  (not  including  tuberculosis). 
Tuberculosis 


Adults 

Children 

382 

178 

1,322 

196 

Grand  Total... 1 ,  704  374 

Opinions  secured  from  the  visiting  nurses  and  checked  by  conferences 
with  their  supervisors,  lead  to  the  conclusion  that  such  medical  attention 
as  was  needed  for  these  patients  in  their  homes  was  generally  secured  by  the 
family  or  on  the  initiative  of  the  visiting  nurse.  The  medical  attention  was 
either  paid  for  or  when  necessary  was  obtained  without  charge  from  an 
interested  physician  or  a  district  physician.  Medical  attention  in  many 
instances  was  or  should  have  been  secured  through  a  dispensary,  since  many 
patients  were  able  occasionally  to  go  out  of  the  house. 


Hospitals  and  Dispensaries  945 

Each  nurse  stated  her  judgment  regarding  each  patient,  as  to  whether 
home  care  was  practicable  or  whether  institutional  care  was  necessary.  In 
887,  or  42.66  per  cent,  of  the  cases,  institutional  care  was  believed  desirable. 
In  the  remaining  1,191  cases,  or  57.33  per  cent.,  it  was  believed  that  home  care 
would  be  adequate.  If  we  omit  for  a  moment  the  tuberculosis  cases,  and  con- 
sider the  560  patients  with  other  diseases,  we  may  estimate  that  less  than  half 
of  these,  or  about  250,  needed  institutional  care,  and  that  the  remaining 
number,  or  about  300,  could  be  cared  for  in  their  homes. 

In  the  special  report  of  the  Survey  on  tuberculosis,  much  attention  is 
given  to  the  shortage  of  sanatorium  facilities,  and  the  need  for  additional 
provision  in  order  that  at  least  all  active  cases  of  tuberculosis  shall  receive 
prompt  and  adequate  institutional  care. 

This  census  of  the  chronic  and  convalescent  cases  in  their  homes  is  of 
course  only  a  very  imperfect  picture.  Only  a  fraction  of  the  total  number  of 
cases  would  be  known  to  any  one  agency,  even  to  the  visiting  nurses,  yet, 
taking  these  figures  simply  as  they  stand,  it  is  apparent  there  were  as  many 
as  two  hundred  persons,  actually  known  to  a  responsible  medical  organiza- 
tion like  the  Visiting  Nurse  Association,  who  it  is  believed  needed  care  in  an 
institution  for  chronic  patients,  and  who  could  not  be  properly  attended  to 
in  their  homes. 

It  would  be  highly  desirable  that  at  least  once  a  year  the  Visiting  Nurse 
Association  should  make  a  similar  canvass  and  classification  of  its  patients 
in  order  that  the  directors,  and  through  them  the  whole  public,  shall  be 
informed  of  these  needs. 

The  problem  of  chronic  illness  must  be  clearly  distinguished  from  that 
of  convalescence.  The  convalescent  patient  is  in  the  process  of  restoration  to 
health.  If  institutional  care  is  needed,  the  period  of  stay  in  a  convalescent 
home  is  as  a  rule  comparatively  short.  Two  to  four  weeks  after  the  usual 
acute  illness  or  surgical  operation  is  generally  sufficient.  The  medical  atten- 
tion required  is  of  quite  a  different  nature  from  that  needed  in  a  case  of 
chronic  illness,  where  a  definite  disease  process  exists  or  there  is  a  definite 
disturbance  of  bodily  function  which  ought  to  receive  close  medical  super- 
vision and  systematic  treatment.  Another  important  practical  difference 
arises  from  the  fact  that  the  chronic  case  is  usually  a  man  or  woman  in  middle 
or  late  life.  To  provide  convalescent  care  for  children  is  an  important  prob- 
lem, whereas  chronic  illness  among  young  persons  is  comparatively  rare. 
Furthermore,  cases  of  chronic  disease  which  cannot  be  cared  for  at  home  are 
largely  among  the  poor  or  those  of  very  limited  means,  and  with  very  unsatis- 
factory home  conditions. 


946  Hospital  and  Health  Survey 

Considering  all  these  points,  it  may  be  said  that  a  very  large  proportion 
of  the  cases  of  chronic  illness  which  require  institutional  care  should  be  the  re- 
sponsibility of  the  city,  rather  than  of  a  private  agency.  There  is,  indeed, 
room  for  a  special  hospital  to  care  for  the  chronic  and  incurable  which  would 
devote  particular  attention  to  the  interesting  but  as  yet  comparatively  un- 
studied medical  problems  of  these  cases  and  which  should  provide  for  part- 
pay  and  pay  patients,  though  having  a  certain  number  of  low  priced  or  free 
beds.  The  need  for  such  an  institution  is  at  present  met  in  Cleveland  only 
by  the  inconsiderable  provision  of  a  few  sanatoria  or  "homes "and  hospitals 
of  the  proprietary  type. 

Eloquent  testimony  to  the  lack  of  present  provision  in  Cleveland  for 
the  chronic  case  is  derived  from  many  of  the  leading  hospitals  of  the  city  in 
which  the  Survey  found  large  numbers  of  patients  who  had  been  in  the  hos- 
pitals a  long  period  of  time.  On  the  two  days,  December  3,  1919,  and  Jan- 
uary 15,  1920,  on  which  a  census  was  taken  in  the  institutions  of  the  Cleve- 
land Hospital  Council,  a  tabulation  was  made  of  the  length  of  time  the  pa- 
tients had  been  in  the  hospitals.  For  this  tabulation,  Warrens ville  Tuber- 
culosis Sanatorium,  Rainbow  Hospital,  St.  Ann's  Maternity  Hospital,  and 
Cleveland  Maternity  Hospital  were  omitted.  The  first  two  of  these  make 
special  provision  for  long  term  cases  and  cannot  be  compared  with  a  general 
hospital,  while  the  latter  two  accept  maternity  cases  only  and  for  this  reason 
should  be  omitted. 

On  December  3rd,  there  were  2,016  hospital  patients  in  the  group  con- 
sidered, and  of  these  243,  or  12.5  per  cent,  had  been  in  the  hospital  for  over 
two  months.  On  January  15th  the  number  of  cases  in  these  hospitals  was 
2,029,  and  the  number  who  had  been  in  the  hospital  over  two  months  was 
286,  giving  again  a  proportion  of  14.1  per  cent. 

The  wide  variation  among  the  individual  hospitals  is  shown  in  Table 
VIII,  in  the  Appendix  in  which  the  figures  for  the  two  census  days  have 
been  averaged  for  the  sake  of  simplicity 

It  is  not  necessarily  true  that  a  patient  who  is  in  a  hospital  over  sixty 
days  is  a  chronic  case,  because  some  patients  with  obscure  diseases  or  who 
are  slowly  recovering  from  illness  or  operation,  may  properly  remain  in  a 
hospital  for  several  months,  but  the  great  bulk  of  these  long-term  patients 
are  cases  of  chronic  illness.  Some  of  these  patients  are  private  cases  and  are 
paying  their  way,  but  the  great  majority  do  not  pay  even  the  cost  of  their 
care.  Aside  from  the  matter  of  payment,  it  is  a  serious  waste  of  service  in  a 
hospital  designed  for  acute  diseases  to  have  to  care  for  chronic  patients. 
It  must  also  be  remembered  that  the  cost  of  giving  adequate  care  for  chronic 
patients  in  a  suitable  institution  is  only  from  one-half  to  two-thirds  of  the 
average  cost  of  maintenance  in  a  hospital  for  acute  diseases. 


Hospitals  and  Dispensaries  947 

From  the  figures  secured  in  the  hospitals  and  presented  in  the  table,  it  is 
probable  that  250  chronic  cases  are  usually  in  Cleveland  hospitals,  in  beds 
which  are  designed  for  acute  cases  and  for  which  there  is  great  demand. 

The  individual  hospital  is  only  in  part  to  blame  for  these  conditions. 
It  is  important  to  see  just  where  the  responsibility  lies  and  what  steps  can  be 
taken  toward  remedy.  A  few  long  term  cases  are  retained  in  acute  hospitals 
because  they  pay  for  the  privilege,  but  these  are  not  the  majority.  No  hos- 
pital however  should  permit  such  patients  to  stay  if  there  is  demand,  as  there 
frequently  is,  for  beds  for  acute  cases.  There  is  a  much  larger  proportion  of  the 
long  term  cases  who  could  be  sent  to  their  homes  and  suitably  cared  for 
therein  if  sufficient  trouble  were  taken  to  make  the  necessary  arrangements 
for  medical  supervision  and  for  attention  at  home.  Adequate  home  care 
of  such  chronic  cases  would  require  the  hospital  to  have  a  social  service  de- 
partment. An  active  social  service  department  in  a  hospital  would  study 
out  the  home  problems  of  the  long  term  patients',  finding  just  what  would  be 
necessary  in  the  way  of  home  provision,  securing  financial  aid  where  this 
would  be  required  and  where  the  cost  would  be  within  reason,  and  enlist- 
ing the  cooperation  of  the  Visiting  Nurse  Association,  the  district  physician, 
or  other  agencies. 

When  it  is  recognized  that  the  cost  of  maintaining  a  chronic  case  in  the 
bed  of  an  acute  hospital  for  a  year  is  almost  equivalent  at  present  to  the 
salary  of  a  social  worker  during  the  year,  and  that  a  social  worker  would  be 
able  to  work  out  the  problems  of  a  large  number  of  such  chronic  patients 
so  they  could  be  cared  for  at  home,  it  is  seen  that  the  present  hospital  policy 
is  "penny  wise  and  pound  foolish."  From  the  standpoint  of  individual 
hospitals,  this  statement  may  be  controverted,  since  the  hospital  would  have 
to  maintain  the  bed  anyway,  and  add  the  salary  of  the  social  worker  in  ad- 
dition. But  from  the  standpoint  of  the  community  and  of  the  Welfare 
Federation  as  representing  the  community,  it  would  be  an  actual  saving  to 
introduce  a  social  worker  and  let  the  bed  occupied  by  one  or  two  chronic 
cases  in  the  course  of  a  year  be  occupied  by  twenty  or  more  acute  cases. 

There  are  also  a  very  large  number  of  chronic  patients  who  do  not  require 
the  amount  of  care  given  in  a  hospital  and  who  are  not  ill  enough  to  be  in 
bed  all  the  time.  These  patients  are  suitable  for  treatment  in  a  doctor's 
office,  or,  in  the  case  of  many,  dispensary  care  is  all  that  is  necessary.  The 
importance  of  dispensary  care  in  chronic  illness  requires  emphasis  for  the 
reason  that  a  great  many  chronic  patients  are  suffering  from  disorders  which 
need  very  careful  medical  study  to  arrive  at  an  accurate  diagnosis,  and  there- 
fore successful  treatment;  and  such  medical  study  often  involves  the  services 
of  one  or  more  specialists,  laboratory  tests,  the  use  of  the  X-Ray,  etc.  The 
expense  of  such  diagnosis  is  beyond  the  resources  of  many  people  who  can 
afford  to  pay  a  doctor  and  who  usually  have  a  family  physician.  The  develop- 
ment of  dispensary  service  in  Cleveland  is  an  important  means  of  providing 
consultant  and  diagnostic  aid.   These  patients,  generally  through  their  family 


948  Hospital  and  Health  Survey 

physician,  could  thus  secure  the  special  study  and  diagnosis  necessary.  An 
enormous  amount  of  physical  distress  and  suffering  and  of  habitual  living  at 
fifty  per  cent,  efficiency,  exists  because  of  the  failure  to  study  out  conditions 
of  a  chronic  nature,  to  arrive  at  a  definite  medical  analysis  of  the  character 
of  the  disorder  and  to  outline  a  plan  of  treatment,  hygiene  and  living  con- 
ditions which  will  restore  the  patient  to  health  or  will  maintain  him  at  the 
highest  physical  grade  possible  for  him.  This  class  of  ambulatory  chronic 
patients  represents  a  very  large  number,  of  which  no  census  anywhere  has 
yet  been  made. 

After  putting  aside  (1)  the  ambulatory  chronic  cases,  (2)  patients  who  are 
entirely  able  to  pay  for  whatever  care  they  need  in  an  institution  or  elsewhere, 
(3)  the  patients  who  could  be  cared  for  in  their  homes  with  social  service 
supervision,  and  (4)  the  tuberculosis  cases  whose  needs  are  studied  elsewhere, 
there  remain  those  who  definitely  must  receive  care  in  a  special  institution 
for  the  chronic  or  the  incurable,  and  who  can  pay  little  or  nothing  for  what 
they  receive. 

To  meet  this  need  is  the  responsibility  of  the  municipality.  Warrens- 
ville  Infirmary  is  the  obvious  institution  which  should  play  this  part  in  behalf 
of  the  city. 


The  Infirmary  occupies  a  well-constructed  building,  built  in  1906,  and 
placed  in  an  excellent  location.  It  operates  a  car  to  meet  the  Chagrin  Falls 
street  car  line.  About  one  hour  is  required  to  reach  Warrenville  from  the 
Cleveland  Public  Square.  Unfortunately,  however,  no  other  provision  than 
street  cars  is  made  for  transporting  patients;  there  is  no  ambulance  service. 
If  a  case  of  contagious  disease  develops  at  Warrenville,  the  patient  must  be 
taken  to  City  Hospital  in  a  truck. 

The  capacity  of  the  Infirmary  is  approximately  900  beds.  In  March, 
1920,  there  were  634  inmates.  Of  these  147  were  insane.  A  further  report 
stated  that  there  were  46  cripples,  41  paralyzed,  and  25  blind,  who  had  been 
in  the  institution  two  or  more  years.  Hardly  more  than  half  of  the  inmates 
in  1918  were  American-born.    There  are  no  interpreters. 

The  personnel  in  charge  of  the*  institution  consists  of  a  Superintendent, 
non-resident,  appointed  by  the  Director  of  Public  Welfare;  a  Medical  Di- 
rector (also  in  charge  of  the  Workhouse  and  the  Girls'  Home),  appointed  by 
the  Director  of  Public  Welfare  and  responsible  to  the  Superintendent;  a 
Matron,  appointed  by  the  Mayor;  and,  at  the  time  of  the  study,  twenty- two 
attendants,  not  all  trained — inmates  being  used  where  possible.  The  General 
Superintendent  of  the  City  Farms  has  some  administrative  control  over  the 
Infirmary. 


Hospitals  and  Dispensaries  949 

From  this  account  it  is  obvious  that  the  Infirmary  has  not  recently  used 
its  capacity,  and  that  there  has  not  been  sufficient  service  to  provide  satis- 
factory care  for  even  those  who  are  there.  On  one  day  on  which  the  institu- 
tion was  visited,  there  was  but  one  attendant  for  three  women's  wards  on 
three  different  floors,  in  which  there  were  120  patients,  40  of  whom  were 
semi-invalid.  One  nurse  is  assigned  to  make  dressings,  fifteen  or  twenty 
being  the  daily  average.  The  Medical  Director  is  so  crowded  with  work, 
as  he  also  has  charge  of  the  medical  service  at  the  Workhouse  and  the  Girls' 
Home,  that  he  can  attend  to  only  the  most  urgent  needs.  He  is  unable  to 
follow  up  complaints  or  to  answer  letters  which  come  to  him  complaining  of 
the  care  of  patients. 

It  was  stated  by  the  Outdoor  Relief  Department  that  a  physical  examina- 
tion was  part  of  the  admission  routine,  the  applicants  being  sent  to  district 
doctors  or  hospital  dispensaries.  There  is  no  provision  for  a  record  of  exam- 
ination on  the  card,  unless  the  diagnosis  and  condition  should  be  mentioned 
in  the  investigator's  report  on  the  reverse  of  the  card.  No  medical  examina- 
tion is  made  on  entry  to  the  institution,  either  for  venereal  diseases  or  for 
any  other  complaint;  neither  is  a  physical  examination  made  afterwards. 

It  is  decidedly  unfortunate  that  in  spite  of  the  urgent  need  for  more  facili- 
ties for  the  care  of  chronic  cases  in  Cleveland,  only  those  patients  who  are 
physically  able  to  care  for  themselves  are  considered  suitable  for  Warrens- 
ville  Infirmary.  Bed-ridden  cases  and  those  which  require  more  or  less 
medical  and  nursing  care  appear  to  be  regarded  as  undesirable. 

With  the  present  shortage  of  help  and  attendants  this  point  of  view  on 
the  part  of  the  officials  can  readily  be  understood,  but  such  a  condition  is  not 
permanently  tolerable.  Here  is  a  well  located  plant  with  900  beds.  In 
Cleveland  are  large  numbers  of  chronic  patients  who  are  cared  for  in  acute 
hospitals  at  undue  expense,  and  with  serious  deprivation  of  service  to  the 
acutely  sick.  The  city  of  Cleveland  should  meet  its  elementary  respon- 
sibility in  providing  enough  money  to  pay  for  medical,  nursing  and  house- 
hold service  required  to  run  Warrensville  Infirmary  to  its  capacity,  so  far  as 
there  is  really  demand  for  it. 

In  extenuation  of  the  present  policy  it  is  fair  to  state  that  conditions  dur- 
ing and  since  the  war  have  made  it  difficult  to  secure  sufficient  personnel, 
yet  the  officials  in  charge  do  not  appear  to  have  made  any  such  determined 
effort  as  the  situation  requires,  to  impress  upon  the  city  administration  and 
also  upon  the  public  at  large,  the  need  of  providing  more  funds  for  Warrens- 
ville, so  that  it  could  care  for  its  inmates  properly  and  so  that  it  could  be 
open  to  all  the  classes  of  patients  who  urgently  require  such  care  as  this 
institution  ought  to  render. 

The  institution  provides  practically  no  therapeutic  facilities ,  such  as 
massage,  mechanical  exercisers,  electro-therapy  or  hydro -therapy.  On  the 
advice  of  a  committee  of  the  Cleveland  Welfare  Federation  studying  the 


950  Hospital  and  Health  Survey 

welfare  of  cripples,  a  trained  occupational  worker  was  employed,  and  in 
October,  1918,  a  workshop  was  opened  for  the  men.  Work  for  the  women 
consists  mainly  of  sewing  and  knitting.  The  provision  of  therapeutic  facili- 
ties would  be  a  great  comfort  to  a  large  number  of  patients.  Further  develop- 
ment of  the  occupational  work  is  highly  desirable. 

It  is  apparent  that  particularly  under  present  conditions,  the  problem  of 
securing  sufficient  nursing  and  attendant  service  is  a  difficult  one,  as  is  the 
related  problem  of  household  help.  The  distance  of  Warrensville  from  the 
city  renders  it  less  desirable  from  the  standpoint  of  many  employes  than  a 
more  accessible  institution.  Higher  wages  will  be  generally  necessary  as  a 
result,  but  even  higher  wages  will  not  themselves  usually  prove  a  sufficient 
inducement,  particularly  when  employment  can  be  secured  readily  by  people 
who  are  even  moderately  trained  at  any  definite  occupation.  The  living 
conditions  must  be  made  not  only  comfortable  but  pleasurable.  The  de- 
velopment of  recreational  facilities  for  those  residing  at  Warrensville  is  a 
practical  step  which  would  be  of  much  service  and  which  would  justify  the 
necessary  expenditure  by  the  city.  It  would  render  possible  the  retention  of 
a  larger  and  certainly  of  a  more  stable  staff,  and  would  save  more  money 
than  it  would  cost. 

From  the  standpoint  of  the  patients,  entertainment  and  recreation  are  a 
very  obvious  measure  of  humanity,  while  from  the  standpoint  of  the  attend- 
ants and  the  help,  they  are  a  practical  measure  of  economical  and  efficient 
administration.  The  management  of  the  Infirmary  could  doubtless  secure 
considerable  assistance  from  various  Cleveland  agencies  interested  in  recre- 
ation. 

A  certain  amount  of  music  and  other  entertainment  can  be  secured  on 
special  occasions  with  little  or  no  expense.  There  is  need  for  some  person 
who  will  be  definitely  in  charge  of  the  recreation  and  social  life  of  the  insti- 
tution, both  for  the  patients  and  for  the  staff  of  nurses,  attendants  and  help. 
Such  a  person  would  develop  many  resources  within  the  personnel  itself,  and 
would  organize  social  and  recreational  activities.  With  a  little  cooperation 
from  the  administration  and  some  expenditure  for  equipment,  music,  etc., 
a  great  deal  could  be  done. 

Steps  should  be  taken  in  making  up  the  next  annual  budget  for  utilizing 
the  Infirmary  to  a  larger  percentage  of  its  capacity,  in  order  to  provide  for 
the  large  number  of  persons  in  Cleveland  who  now  need  institutional  care 
as  chronic  patients.  There  are  at  least  two  hundred  such  patients  now 
occupying  beds  in  acute  hospitals  in  Cleveland,  to  the  detriment  of  these 
hospitals'  service,  while  really  acute  cases  must  moreover  be  turned  away 
for  lack  of  beds.  If  Warrensville  can  be  provided  with  sufficient  staff  to 
make  care  satisfactory  for  the  inmates,  it  would  undoubtedly  be  possible  to 
keep  it  full  up  to  nearly  if  not  quite  all  its  capacity  of  nine  hundred  beds. 

To  sum  up  the  situation  in  Cleveland  regarding  chronic  illness  and  its 
care,  it  may  be  stated  that: 


Hospitals  and  Dispensaries  951 

1.  There  are  at  present  at  all  times  several  hundred  patients  in  the  hospitals  of  Cleve- 
land, designed  for  acute  cases,  who  are  chronic  cases  and  should  not  be  in  these  hospitals 
at  all. 

2.  As  a  result,  hospital  service  is  rendered  less  available,  and  the  acutely  sick  must 
often  be  denied  needed  care  because  beds  are  taken. 

3.  There  are  very  large  numbers  of  ambulatory  chronic  cases  who  require  study  by 
specialists,  the  aid  of  laboratories  and  of  other  diagnostic  apparatus  in  order  that  they  may 
receive  sufficient  medical  study  to  be  properly  treated.  The  shortage  of  dispensary  and 
consultant  service  for  the  physicians  of  Cleveland  at  present  renders  it  impracticable  for 
many  of  these  patients  to  secure  what  they  need. 

4.  The  lack  of  a  sufficient  number  of  privately  supported  institutions  furnishing  a 
high  grade  of  care  for  chronic  cases  who  can  pay,  forces  the  acute  hospitals  to  retain  a 
number  of  such  patients  and  leaves  the  remainder  to  be  inadequately  cared  for  at  home 
or  in  the  few  small  proprietary  institutions  who  seek  such  work.  There  is  undoubtedly 
place  for  a  well-managed  institution  for  chronics,  which  could  be  largely  or  wholly  self- 
supporting. 

5.  Adequate  social  service  departments  would  enable  a  considerable  number  of  chronic 
cases  now  in  acute  hospitals  to  be  cared  for  properly  in  their  homes.  A  definite  economy 
to  the  community  would  result.  This  is  an  additional  reason  for  the  increase  of  hospital 
social  service  in  Cleveland,  the  need  for  which  is  more  fully  discussed  in  the  next  chapter. 

6.  Provision  for  those  chronically  ill  who  cannot  be  cared  for  at  home  and  who  cannot 
pay  their  way  in  an  institution,  is  a  primary  responsibility  of  the  municipaltiy.  War- 
rensville  Infirmary  has  the  space  and  needs  the  additional  personnel  with  which  to  meet 
this  responsibility.  There  should  be  unremitting  effort  by  the  Department  of  Public 
Welfare  until  funds  are  provided  for  this  purpose.  Such  chronic  cases  should  not  be 
retained  in  any  considerable  numbers  at  City  Hospital,  whereas  as  many  as  300  beds 
could  well  be  used  at  Warrensville,  not  including  in  this  number  those  who  are  crippled 
or  merely  infirm  from  age. 

7.  The  large  number  of  tuberculosis  patients  found  in  their  homes  by  the  Survey 
emphasizes  the  need,  brought  out  in  the  special  report  on  tuberculosis,  for  increase  in 
sanatorium   provision. 


952  Hospital  and  Health  Survey 


SOCIAL  SERVICE  IN  HOSPITALS  AND  DISPENSARIES 

It  is  only  fourteen  years  since  the  first  hospital  social  service  department 
in  the  United  States  was  established  in  Boston.  Today  over  three  hundred 
hospitals  have  taken  on  this  new  and  important  adjunct  to  their  medical 
service.  It  is  curious  that  a  community  so  advanced  as  is  Cleveland  in  many 
respects  should  have  made  only  a  slight  development  in  the  social  service 
activities  of  its  hospitals  and  dispensaries. 

Three  hospitals  in  Cleveland  have  organized  social  service  departments. 
Four  other  institutions  have  each  one  person  who  is  devoting  some  atten- 
tion to  social  and  financial  relationships  connected  with  patients.  The 
Lakeside  Hospital  Social  Service  Department  has  been  in  existence  seven 
years,  that  at  Mt.  Sinai  three  years,  and  that  at  St.  Vincent's  Charity  Hos- 
pital one  year.  Each  of  these  social  service  departments  began  with  one 
worker.  Lakeside  had  six  workers  at  the  beginning  of  1920;  Mt.  Sinai  four 
and  Charity  five.  These  departments  have  developed  independently  and 
there  has  been  no  uniformity  in  policy. 

At  Lakeside,  the  social  service  department  appears  to  be  an  outgrowth  of 
the  visiting  nursing  service.  For  a  number  of  years  its  activities  have  been 
almost  entirely  confined  to  the  dispensary,  and  its  head  worker  was  prac- 
tically responsible  for  admission  of  patients  and  for  many  details  of  dispen- 
sary administration.  It  is  unfortunate  that  for  a  number  of  years  this  de- 
partment has  maintained  a  policy  of  medical  secrecy  which  has  prevented 
its  meeting  the  needs  of  agencies  such  as  the  Associated  Charities  or  making 
a  contribution  to  the  community  health  problem.  To  furnish  to  a  charitable 
agency  information  regarding  the  medical  condition  and  the  health  needs  of 
patients  in  whom  the  agency  is  interested  is  part  of  the  responsibility  of  a 
hospital  or  dispensary.  To  effectuate  this  relationship  between  the  hos- 
pital and  the  outside  non-medical  charity  is  part  of  the  duty  of  the  social 
service  department.  Lack  of  records  in  the  social  service  department  at 
Lakeside  has  rendered  it  impossible  to  study  the  social  conditions  which 
cause  disease  or  which  render  its  successful  treatment  impracticable  unless 
they  are  altered.  Although  Lakeside  Dispensary  is  a  teaching  clinic  of 
Western  Reserve  University  Medical  School,  the  social  work  is  not  so  con- 
nected with  the  organization  as  to  bring  the  medical  students  in  contact 
with  it  and  enable  them  to  learn  something  of  the  relationship  between  the 
medical  and  social  problems.  This  has  been  done  in  a  number  of  other 
leading  medical  schools,  notably  in  that  of  Indiana  University. 

At  Mt.  Sinai  Hospital,  the  social  service  department  was  organized  as  a 
definite  part  of  the  dispensary,  and  has  been  much  more  intimately  related 
to  the  medical  service  on  the  one  side,  and  to  the  social  and  charitable  agencies 
on  the  other.  As  at  Lakeside,  a  considerable  part  of  the  time  of  the  social 
service  staff  has  been  spent  in  assisting  in  the  administration  of  the  dis- 
pensary. As  at  Lakeside,  a  lack  of  clerical  assistance  has  made  adequate 
records  impracticable,  so  that  much  of  the  research  value  of  the  work  has 
been  lost. 


Hospitals  and  Dispensaries  953 

The  recently  developed  department  at  St.  Vincent's  Hospital  is  like  the 
others,  largely  concerned  with  the  dispensary  rather  than  with  the  hospital 
cases.  Lack  of  clearly  defined  policy  other  than  to  do  kindly  and  friendly 
things  for  patients  is  apparent  here  as  often  elsewhere  in  this  new  branch  of 
service. 

In  the  prenatal  clinic  at  St.  Luke's*  Hospital  a  nurse  spends  half  her  time 
admitting  dispensary  patients  and  in  making  financial  investigations  for  the 
hospital,  and  this  is  called  social  service. 

At  the  Babies'  Dispensary  a  graduate  nurse,  called  a  "social  service 
nurse,"  is  responsible  for  the  admitting  of  new  patients,  and  classifies  them 
according  to  their  ability  to  pay  the  various  grades  of  fees  in  this  institu- 
tion— admitting  them  or  referring  them  elsewhere  according  to  her  judg- 
ment. 

At  City  Hospital  there  has  been  a  single  worker,  who  without  any  definite 
policy  or  guidance,  has  endeavored  to  mitigate  personal  or  other  problems 
for  those  few  patients  she  could  reach  among  the  thousands  passing  through 
that  institution  yearly. 

At  Rainbow  Hospital  is  a  "social  service  nurse,"  who  does  follow-up 
work  for  the  children  who  are  discharged. 

In  addition  to  the  activities  of  these  seven  institutions,  the  Association 
for  the  Crippled  and  Disabled  maintains  a  social  service  department  of  a  dis- 
tinctive and  efficient  sort.  While  not  properly  speaking  a  hospital  social 
service  department,  its  work  is  of  very  simila  character.  A  description  and 
evaluation  of  this  will  be  found  in  the  portio.i  of  Part  II.  which  deals  with 
the  care  of  cripples. 

The  most  striking  fact  about  hospital  and  dispensary  social  service  in 
Cleveland  is  the  lack  of  any  definite  conception  of  the  policy  which  a  social 
service  department  should  pursue  and  of  its  relationship  to  the  organization 
of  the  institution  in  which  it  works.  In  no  department  does  there  appear 
to  be  a  clear  recognition  that  the  prime  basis  of  social  service  in  a  hospital 
or  dispensary  is  the  assistance  of  medical  treatment.  Social  service  is  not 
or  rather  should  not  be  in  a  medical  institution  for  the  sake  of  being  kind  to 
patients,  or  for  the  sake  of  finding  out  what  patients  can  pay  the  hospital 
fees,  or  for  the  sake  of  helping  to  run  the  dispensary. 

Kindness  is  a  general  function  of  a  hospital  organization — not  an  attri- 
bute of  social  service  in  particular.  The  fixing  of  fees  or  finding  out  whether 
patients  can  pay  is  an  administrative  function,  to  be  performed  by  a  financial 
investigator.  It  is  a  serious  interference  to  any  really  constructive  social 
service  to  patients  if  the  worker  who  is  supposed  to  render  such  service  is 
placed  in  the  position  of  an  inquisitor  into  the  details  of  personal  income. 


954  Hospitals  and  Dispensaries 

Helping  to  admit  patients  to  a  hospital  or  dispensary  or  to  administer  a 
dispensary  is  a  useful  and  necessary  service  which  social  workers  have  often 
been  called  upon  to  do  since  no  other  trained  persons  have  been  available, 
particularly  in  a  dispensary.  Social  workers  have  been  rendering  such  ad- 
ministrative assistance  in  several  dispensaries  of  Cleveland  as  in  other  cities, 
and  have  been  of  substantial  value  to  their  institution  and  to  the  patients 
by  doing  so.  It  is  quite  true  that  assistance  in  many  phases  of  administra- 
tive work  in  hospitals  and  dispensaries  falls  naturally  to  social  service.  When 
these  pieces  of  administration  involve  personal  dealings  with  patients  (as  in 
admissions  or  in  the  management  of  clinics)  the  training  and  practical  ex- 
perience of  the  social  worker  is  of  distinct  value. 

Physicians  in  a  hospital  do  various  things  which  a  layman  might  do, 
such  as  making  records  or  assisting  in  administration;  so  also  nurses  do 
many  things  for  which  their  special  training  as  nurses  is  not  a  pre-requisite, 
but  the  essential  reason  which  brings  a  doctor  to  a  hospital  is  the  activity 
which  he  alone  is  trained  to  perform — medical  diagnosis  and  treatment. 
The  reason  why  nurses  are  in  hospitals  is  because  there  are  certain  duties 
which  only  trained  nurses  can  perform — the  bodily  care  of  patients  and 
assistance  of  physicians  during  operations  and  in  therapy.  The  distinctive 
function  of  social  service  which  brings  the  social  worker  in  the  hospital  and 
dispensary  is  the  contribution  which  she  can  make  to  medical  treatment, 
assisting  the  physician  in  securing  those  facts  about  the  patient's  personality 
and  environment  which  will  bear  upon  the  cause  and  characteristics  of  his 
disease,  and  aiding  the  physician  in  planning  and  carrying  out  the  details  of 
treatment  which  under  the  conditions  of  the  patient's  character,  family,  and 
finances,  are  necessary  to  secure  the  best  results. 

In  the  hospitals  and  dispensaries  of  Cleveland,  social  service  has  been 
largely  introduced  as  a  measure  of  kindness  and  as  a  helpful  agent  in  adminis- 
tration. There  has  nowhere  been  recognition  of  any  definite  policy  or  of  the 
essential  relationships  between  hospital  social  service  and  medical  treat- 
ment. 

A  trained  social  worker  is  one  who  has  learned  to  make  critical  but 
sympathetic  judgments  of  the  human  problems  usually  presented,  and  who 
has  also  learned  how  these  can  be  dealt  with  effectively  in  practice.  As  an 
example  of  the  questions  which  face  medical  and  social  workers  and  which 
need  trained  social  judgment  for  their  answer,  we  may  cite: 

Shall  material  relief  be  obtained  for  a  family  for  the  three  or  four 
months  during  which  the  father  will  be  in  an  institution  because  of  sick- 
ness, or  shall  the  five  children  and  mother  be  placed  in  four  different  homes 
of  willing  relatives  during  that  period — a  course  to  which  the  mother  strenu- 
ously objects? 

Shall  a  delicate  child  with  kind-hearted  but  quarrelsome  and  unedu- 
cated parents,  be  placed  in  a  country  home  for  six  months;  or  shall  an  at- 
tempt be  made,  through  the  parents'  love  for  the  child,  to  reconstitute 
family  life  sufficiently  to  enable  the  girl  to  get  well  at  home? 


Hospitals  and  Dispensaries  955 

Shall  an  unmarried  pregnant  girl  of  21  be  urged  to  marry  the  father 
of  her  child  if  the  man  is  willing,  although  the  girl  has  lost  her  confidence  in 
him,  or  shall  she  be  helped  to  fight  her  battle  of  life  alone?* 

The  answer  to  such  questions  requires  in  the  first  instance,  careful  study 
by  the  social  worker  of  the  patient's  personality  and  family  circumstances, 
reporting  to  the  physician  and  deciding  in  conjunction  with  him  the  proper 
course  to  pursue,  having  both  medical  and  social  facts  in  mind. 

There  is  very  little  indication  from  the  studies  made  of  the  work  of  the 
social  service  departments  in  Cleveland  that  this  type  of  analysis  is  prac- 
tised in  its  definite  relations  to  the  medical  problem  of  each  case.  The 
character  of  the  disease  is  of  vital  influence  in  determining  what  treatment 
is  necessary,  but  how  the  treatment  shall  be  applied  depends  in  a  large 
measure  upon  the  patient's  personality  and  environment. 

In  addition  to  the  study  and  analysis  of  the  case  necessary  to  form  judg- 
ment as  to  the  social  causes  of  the  disease  and  of  the  conditions  which  will 
affect  its  treatment,  the  social  worker  in  the  hospital  or  dispensary  must  also 
endeavor  to  help  in  the  accomplishment  of  the  treatment,  as  by  finding  a 
job  for  a  man  with  a  damaged  heart,  getting  food  or  money  for  an  under- 
nourished family  with  three  sickly  children,  or  by  securing  a  vacation,  a 
friendly  visitor,  or  the  help  of  a  relative  so  that  a  woman  will  consent  to  have 
an  operation  in  the  hospital,  knowing  that  her  children  are  properly  cared 
for  meanwhile.  In  these  types  of  practical  service,  where  the  problem  is 
rather  obvious,  persistence  and  resourcefulness  are  often  shown  among  the  cases 
studied  in  the  Cleveland  social  service  departments,  but  because  of  the  com- 
bination of  lack  of  definite  policy  and  of  pressure  of  administrative  work, 
there  has  been  little  real  study  of  cases  so  as  to  bring  out  relationships  be- 
tween disease  and  social  conditions,  thus  enabling  a  really  definite  and  well 
rounded  plan  to  be  made  for  combined  medical  and  social  treatment. 

It  must  be  apparent  that  in  many  cases  where  the  personality  of  pa- 
tients or  family  difficulties  or  lack  of  funds  are  involved,  medical  treatment 
is  largely  or  wholly  wasted  unless  adequate  social  service  goes  with  it.  The 
primary  and  fundamental  recommendation  therefore  for  the  social  service 
departments  of  Cleveland  is  a  definite  aim — a  clear-cut  policy. 

The  need  for  sufficient  medical  social  service  in  the  Cleveland  City  Hos- 
pital is  the  outstanding  requirement  when  individual  institutions  are  con- 
sidered. In  a  large  municipal  institution  of  this  sort  the  great  majority  of 
the  patients  come  from  home  conditions  which  render  convalescence  difficult 
(as  has  been  shown  in  the  section  on  "The  Convalescent  and  the  Hospital") 
or  the  hospital's  care  is  of  greatly  diminished  value  in  restoring  the  individual 
or  family  to  health  unless  something  more  is  done  than  simply  to  provide 
the  surgical  operation  or  bed  care  during  an  acute  illness. 

*  Davis  8b  Warner,     "Dispensaries."     1918.     Page  114. 


956  Hospital  and  Health  Survey 

Waste  of  human  energy,  increase  of  human  suffering,  and  fruitless  ex- 
penditure of  public  funds  goes  on  at  any  large  municipal  hospital  without 
social  service — the  institution  can  merely  render  medical  attention  during 
the  acute  stage  of  an  individual's  illness,  and  passes  by  related  conditions  in 
the  man  or  in  his  home  or  his  occupation. 

Re-occurrence  of  illness,  re-admission  to  the  hospital,  lowered  efficiency  of 
the  patient  and  family,  further  illness,  and  family  deterioration,  make  a 
vicious  circle  which  the  most  skilled  surgeon  and  finest  diagnostic  equipment 
cannot  break  alone. 

In  New  York,  Bellevue  Hospital,  with  1,300  beds,  has  a  social  service  de- 
partment with  30  workers.  In  Boston,  the  City  Hospital,  an  institution 
only  a  little  larger  than  the  City  Hospital  of  Cleveland,  and. much  smaller 
than  the  enlarged  City  Hospital  which  Cleveland  will  soon  possess,  has  17 
social  workers.  At  the  Cook  County  Hospital,  Chicago,  there  is  a  social 
service  department  with  8  workers,  and  in  the  social  service  department  of 
Cincinnati  General  Hospital,  there  are  4  workers. 

The  larger  the  institution,  moreover,  the  greater  is  the  need  that  the  head 
worker  be  a  person  of  unusual  personality  and  previous  definite  experience 
in  hospital  social  service.  The  Cleveland  City  Hospital  needs  an  adequate 
social  service  department  with  a  strong,  well-trained  woman  at  its  head. 
She  should  be  responsible  to  the  superintendent  of  the  hospital,  but  there 
should  be  a  social  service  advisory  committee  appointed  by  the  Director  of 
Public  Welfare  (or  by  the  board  of  trustees  if  such  a  board  is  formed  for  the 
City  Hospital).  The  duties  of  such  social  service  committees  are  touched 
upon  later  in  this  chapter.  This  committee  would  be  of  particular  impor- 
tance to  City  Hospital  during  the  first  years  of  development  of  adequate 
social  service  there. 

It  may  be  mentioned  that  some  years  ago  a  social  service  department 
was  started  in  the  Boston  City  Hospital  on  the  initiative  of  a  number  of 
private  citizens,  including  some  of  those  closely  associated  with  the  institu- 
tion by  medical  interests.  Private  funds  supported  the  original  staff,  but 
the  city  soon  entered  and  paid  a  share  as  the  department  enlarged.  While 
at  present  some  of  the  staff  of  workers  are  still  supported  by  private  funds, 
the  outcome  will  undoubtedly  be  complete  municipal  support.  At  no  time, 
however,  has  there  been  any  question  of  division  of  responsibility  for  im- 
mediate control  by  the  hospital.  In  a  municipality  with  the  active  civic 
spirit  of  Cleveland  such  initial  sharing  of  the  burden  of  hospital  social  service 
by  private  funds  ought  not  to  be  necessary;  but  it  is  not  at  all  undesirable. 

The  Welfare  Federation  has  certain  special  reasons  for  supporting  social 
service  in  hospitals  and  dispensaries.  A  very  large  proportion  of  poverty  is 
caused  by  sickness  or  is  accompanied  by  sickness,  making  it  useless  to  attempt 
to  restore  the  family  to  self-support  until  the  illness  has  been  successfully 
treated.  Studies  in  a  number  of  cities  indicate  that  sickness  is  one  of  the 
conditions  accompanying  poverty  in  from  60  to  80  per  cent,  of  the  families 
known  to  such  an  agency  as  an  Associated  Charities.  Since  the  members  of 
such  families  obviously  cannot  afford  a  private  doctor,  it  may  be  said  that 


Hospitals  and  Dispensaries  957 

the  hospital  and  dispensary  must  be  their  family  physician.  The  charitable 
agency  must  look  to  the  hospital  and  dispensary  for  medical  diagnosis, 
advice  and  treatment,  and  the  agency  requires  the  constant  cooperation  of 
the  hospital  and  dispensary.  Without  the  social  service  department  this 
cooperation  generally  proceeds  with  halting  steps.  The  social  service  de- 
partment is  the  link  between  the  highly  organized,  specialized  medical  insti- 
tution and  the  community  agency  which  deals  with  the  family  in  its  home. 
Without  such  a  link,  much  money  and  much  time  are  wasted  by  these  agen- 
cies. Thus  it  is  not  only  in  behalf  of  the  intrinsic  service  to  the  patients  of 
hospitals  and  dispensaries  that  social  service  has  a  claim  to  support,  but  also 
because  the  work  of  other  charitable  agencies  which  are  members  of  the 
Welfare  Federation  will  be  very  substantially  assisted  thereby. 

The  special  need  of  hospital  social  service  in  connection  with  the  con- 
valescent and  the  chronic  case  has  been  brought  out  in  the  preceding  chapters. 

The  section  dealing  with  the  plan  of  hospital  organization  includes  a  brief 
statement  concerning  social  service.  A  social  service  department  should  be 
part  of  the  hospital  organization,  not  maintained  by  any  outside  agency. 
Social  service  needs  to  work  intimately  within  the  hospital  and  hence  to  be 
an  integral  part  of  its  administration.  The  head  worker  of  the  social 
service  department  should,  like  the  heads  of  other  departments,  be  respon- 
sible to  the  superintendent,  but  it  is  advisable,  particularly  during  the 
formative  stages  of  social  service,  to  have  a  social  service  committee,  includ- 
ing a  few  members  of  the  board  of  trustees,  one  or  more  members  of  the 
medical  staff,  the  superintendent  ex-officio  and  other  persons  who  are 
familiar  with  general  philanthropic  work  and  whose  advice  regarding  the 
policy  and  problems  of  the  department  will  be  of  value.  Such  a  committee 
should  be  advisory,  like  others  suggested  in  the  scheme  of  organization. 

The  personality  of  the  head  worker  and  the  quality  of  her  training  and 
experience  are  of  vital  importance  to  a  social  service  department.  There 
has  been  in  Cleveland,  as  in  a  few  other  cities,  much  discussion  as  to  the 
training  necessary  for  a  hospital  social  worker,  and  in  particular  of  her  rela- 
tion to  nursing.  A  nurse's  training  does  not  provide  one  of  the  essential 
elements  for  a  hospital  social  worker,  nor  can  this  be  gained  by  a  brief  period 
of  observation  of  social  service  or  by  a  two  or  three  months'  "course."  Not 
less  than  one  year's  study  of  social  work  and  an  additional  year  of  practical 
experience  under  educational  supervision  is  necessary  to  render  any  person 
a  competent  worker  in  so  difficult  and  complex  a  field  as  this.  The  training 
of  a  nurse  provides  important  knowledge  of  medical  matters  and  a  familiar- 
ity with  the  point  of  view  of  physicians  and  patients,  and  with  the  conduct 
and  administration  of  hospitals  and  dispensaries.  Actual  experience  in  many 
social  service  departments  throughout  the  country  has  proved  that,  as  a 
matter  of  fact,  some  successful  workers  are  nurses  and  that  some  of  them 
are  not  nurses,  and  that  to  debate  as  to  whether  a  hospital  social  service 
worker  must  be  a  nurse  or  must  not  be  a  nurse  is  merely  a  waste  of  time. 
Personality  implying  effectiveness  in  dealing  with  people,  a  certain  degree 
of  administrative  and  executive  ability,  and  a  definite  training  in  the  analysis 
of  social  problems  and  familiarity  with  the  methods  of  dealing  with  them, 


958  Hospital  and  Health  Survey 


are  essential  elements,  as  well  as  certain  subject-matter  concerning  partic- 
ular diseases  or  medical  problems  to  be  dealt  with.  During  the  present  form- 
ative period  of  social  service,  too  much  care  cannot  be  taken  in  selecting 
the  right  quality  of  head  worker,  and  then  leaving  it  largely  to  her  to  nomi- 
nate and  appoint  her  assistants. 

Social  service  in  the  hospital  and  dispensary  must  be  viewed  primarily 
asjan  adjunct  of  medical  treatment.  It  is  usually  desirable  that  social  serv- 
ice shall  assist  in  various  administrative  activities,  as  in  connection  with  the 
admission  of  hospital  patients,  the  admissions  to  the  dispensary  or  the 
management .  of  dispensary  clinics. 

It  is  not  desirable,  however,  that  a  member  of  the  social  service  depart- 
ment should  be  used  as  the  financial  investigator  of  the  hospital.  The  utiliza- 
tion of  social  workers  at  the  admission  desk  of  a  dispensary  is  desirable,  but 
the  financial  grading  of  patients  should  not  be  her  primary  responsibility, 
nor  should  financial  grading  be  of  such  rigidity  as  exists  at  the  Babies'  Dis- 
pensary, or  existed  until  recently,  at  Mount  Sinai.  Such  rigid  grading  tends 
to  develop  arbitrary  standards  of  dealing  with  patients,  on  an  entirely  super- 
ficial basis,  establishing  a  wrong  relationship  with  a  patient  by  emphasizing 
his|financial  rather  than  his  physical  need.  It  is  well  that  Mount  Sinai  has 
discarded  the  custom. 

It  may  be  added  that  it  is  not  desirable  to  have  any  person  kept  continu- 
ously at  the  desk  admitting  patients  to  hospital  or  dispensary  without  being 
assigned  a  portion  of  her  time  to  other  phases  of  social  service,  particularly 
the  study  of  families  in  their  homes.  The  admission  of  patients  requires  a 
series  of  "snap  judgments,"  based  necessarily  on  slight  information.  In 
order  to  keep  any  person  from  becoming  "routinized,"  losing  freshness  and 
flexibility,  the  effect  of  making  necessarily  hasty  judgments  in  the  admission 
of  patients  must  be  counteracted  by  giving  the  worker  some,  even  if  only  a 
small  amount,  of  time  for  intensive  observation  and  service  with  a  few  pa- 
tients in  their  homes. 

In  a  dispensary  the  social  worker  can  be  of  value  not  only  at  the  admis- 
sion desk,  but  in  various  phases  of  dispensary  administration,  notably  in 
the  detailed  executive  management  of  clinics.  The  routine  of  the  clinic 
needs  adaptation  to  the  needs  of  each  patient.  The  doctors'  time  should 
not  be  taken  up  with  executive  detail  but  should  be  given  to  medical  work. 
The  social  worker,  as  clinic  executive,  is  a  great  aid  alike  to  physician  and 
patient. 

The  Social  Service  Clearing  House  supported  by  the  Associated  Charities 
provides  (a)  registration  of  families  known  to  charitable  agencies.  By  means 
of  this  there  is  at  the  office  of  the  Clearing  House  a  list  of  families  or  "cases" 
known  to  any  agency  using  the  Clearing  House,  and  with  the  name  of  each 
case  or  family  is  a  list  of  the  agencies  which  have  been  interested  in  this  case. 
The  Clearing  House  also  provides  for  (b)  answering  inquiries  from  agencies 
about  families  and  telling  them  whether  any  other  charitable  agencies  are 
interested  in  the  family,  and  if  so,  what  agencies.     By  this  means  a  charit- 


Hospitals  and  Dispensaries  959 

able  agency  may  find  out  the  names  of  those  who  have  previously  known 
a  family  and  then,  by  calling  these  agencies,  learn  what  has  been  or  is  being 
done  for  the  family. 

The  Clearing  House  is  very  largely  used  by  hospitals  and  dispensaries  of 
Cleveland.  During  1919  a  total  of  39,569  inquiries  were  made,  and  of  this 
total  of  25,966  or  43  per  cent,  were  from  medical  agencies,  chiefly  dispensaries. 
Such  registration  takes  place  largely  through  the  social  service  departments  of 
the  dispensaries  and  through  the  nurses  in  the  health  centers. 

Registration  of  dispensary  cases  in  the  Social  Service  Clearing  House, 
however,  is  not  accompanied  by  full  use  of  the  information,  thus  secured. 
When  the  dispensary  registers  a  case  it  learns  automatically  by  the  reply 
slip,  sent  from  the  Clearing  House,  the  names  of  the  agencies  who  have 
formerly  known  the  family.  If  the  social  service  department  of  the  dis- 
pensary does  nothing  further  the  time  spent  in  registering  the  family  is  prac- 
tically wasted.  It  is  found  that  in  a  large  number  of  cases  no  use  of  the  in- 
formation secured  from  the  Clearing  House  is  made. 

The  Social  Service  Clearing  House  is  a  most  important  means  of  promot- 
ing team  work  among  agencies  and  of  avoiding  overlapping  in  dealing  with 
families.  Its  use  should  be  increased  in  every  way,  but  it  is  a  question  how 
far  mere  registration  without  making  use  of  the  information  is  worth  while. 

It  is  recommended  that  a  conference  be  held  of  representatives  of  the 
Associated  Charities  maintaining  the  Clearing  House  and  of  a  number  of 
representatives  from  medical  agencies,  particularly  the  large  dispensaries 
and  health  centers,  and  that  the  following  questions  of  policy  be  discussed 
and,  if  possible,  decided. 

1.  Shall  it  be  the  policy  of  the  agency  to  register  all  cases,  or  only  cases 
in  which  it  is  likely  that  they  will  make  use  of  the  information  secured  from 
the  Clearing  House? 

2.  If  the  latter,  decision  should  be  reached  by  each  agency  as  to  what 
types  of  cases,  classified  in  medical  or  in  other  ways,  they  will  register,  and 
the  Clearing  House  should  be  informed  of  this  policy  and  of  changes  from 
time  to  time. 

It  is  desirable  that  as  large  a  number  of  cases  be  registered  as  possible, 
but  mere  waste  of  effort  in  futile  registration  should  be  avoided.  It  is  neces- 
sary to  draw  the  line  at  the  right  point,  given  a  certain  sized  social  service 
and  clerical  staff  in  each  medical  organization. 

It  is  not  deemed  advisable  that  a  routine  social  history  be  taken  of  every 
patient,  as  is  done  in  some  clinics,  notably  at  Mount  Sinai.  Many  facts  of 
value  are  found  through  conference  between  social  worker  and  patient,  but 
unless  there  are  enough  social  workers  to  take  up  these  cases  and  deal  with 
the  needs  found,  the  time  taken  in  getting  a  thorough  social  history  is  largely 


960  Hospital,  and  Health  Survey 

or  wholly  wasted  in  many  instances.  Unless  a  dispensary  has  a  very  unusual 
number  of  social  workers,  such  as  no  dispensary  in  Cleveland  has  at  the 
present  time  or  is  likely  to  have  in  the  near  future,  it  is  advisable  that  detailed 
social  histories  be  taken  only  on  selected  cases,  the  social  worker  at  the 
admission  desk  or  in  the  clinic  determining  (on  necessarily  brief  judgment) 
which  cases  shall  be  selected. 

Social  service  departments  have  generally  suffered  from  lack  of  sufficient 
clerical  assistance  to  keep  adequate  records  which  are  required  in  social  serv- 
ice as  in  medicine,  for  good  work.  Furthermore,  it  is  not  economical  to 
take  a  large  part  of  the  time  of  a  social  worker  for  clerical  tasks. 

Finally,  it  is  urged  that  a  definite  portion  of  the  time  of  the  head  social 
worker  or  of  one  of  her  best  assistants  be  devoted  to  the  constant  study  of 
the  social  problems  of  the  hospital  and  dispensary,  and  their  interpretation 
to  the  staff  and  the  administrative  authorities  of  the  institution.  Periodical 
studies  of  the  social  problems  of  selected  groups  of  patients  are  practicable 
even  in  a  small  social  service  department,  if  the  groups  selected  are  small, 
buff  judiciously  chosen  so  as  to  be  medically  and  otherwise  significant.  Such 
studies  and  reports  on  the  social  problems  of  these  patients  outline  to  the 
staff  and  the  administration  the  social  conditions  influencing  some  of  the 
chief  diseases  treated  in  the  hospital  and  dispensary.  Only  in  that  way  can 
the  policy  of  the  social  service  department  be  expected  to  grow,  and  the 
hospital  and  dispensary  steadily  advance  in  a  broad  policy  of  prevention  as 
well  as  cure,  and  of  widening  service  to  the  community. 


Hospitals  and  Dispensaries  961 


AMBULANCE  SERVICE 

To  understand  what  the  ambulance  system  of  Cleveland  ought  to  be  it 
is  necessary  first  to  outline  the  present  situation. 

There  are  three  different  agencies  in  Cleveland  which  may  be  called 
upon  for  ambulance  service.  The  Police  Department  has  "Police  Emer- 
gency" cars,  used  for  the  sick  or  for  the  law-breaker,  as  the  need  may  be. 
Cily  Hospital  owns  three  ambulances  (two  Atlas  cars  and  one  Ford)  but 
has  only  one  in  commission.*  The  Survey  was  informed  that  each'  of  the 
local  undertakers,  of  which  there  are  over  100,  has  one  or  more  "combination- 
wagons"  (combination  "dead-wagon"  and  invalid  carriage). 

From  January  to  November,  1919,  the  police  answered  a  total  of  3,290 
ambulance  calls.  The  City  Hospital  ambulance  was  out  of  repair  for  five 
months  of  1919,  but  during  the  other  seven  months  made  937  calls.  The 
number  of  calls  answered  by  the  undertakers  could  not  be  estimated. 

In  contrast  with  these  provisions  may  be  cited  the  provisions  found  in 
several  other  leading  cities.  In  New  York  City  the  ten  public  hospitals 
operate  31  ambulances,  and  in  addition,  35  private  hospitals  provide  a  total 
of  70  ambulances.  The  City  Hospital  in  Providence,  Rhode  Island,  has 
three  ambulances.  In  Jersey  City  the  City  Hospital  has  six  ambulances. 
In  Philadelphia  about  35  private  hospitals  own  ambulances  and  their  serv- 
ices for  emergency  work  are  recognized  by  an  annual  appropriation  of  $300 
to  each  hospital  from  the  city. 

The  distribution  of  ambulances  has  an  important  bearing  upon  their 
availability  and  promptness  in  answering  calls.  A  police  ambulance  is  sta- 
tioned at  each  of  the  fifteen  police  precinct  stations  of  Cleveland  except  at 
Precincts  4,  10  and  15.  The  City  Hospital  ambulance  is  expected  to  serve 
the  entire  city,  and  the  service  of  the  ambulances  provided  by  the  undertakers 
is  not  districted.  Calls  for  the  Police  Emergency  are  supposed  always  to  be 
sent  to  the  Police  Information  Bureau,  and  then  to  be  relayed  to  the  nearest 
precinct  station,  although  they  may  be  received  directly  at  the  precinct  sta- 
tion itself.  If  the  emergency  patrol  at  the  nearest  precinct  station  is  not 
available,  the  call  is  transferred  to  another  district  office.  So  far  as  could 
be  ascertained,  there  is  nothing  to  prevent  a  person  from  calling  the  police 
emergency,  City  Hospital  ambulance  and  an  undertaker's  car,  for  the  same 
emergency  case. 

In  a  matter  where  a  few  minutes  time  may  be  of  such  vital  significance, 
the  promptness  with  which  ambulance  calls  are  answered  is  of  decided  im- 
portance. The  consensus  of  local  opinion  seemed  to  be  that  the  police 
emergency  cars  were  prompt  in  arriving,  but  there  was  universal  criticism 
of  the  utter  unreliability  of  the  City  Hospital  ambulance  in  answering  calls. 
Delays  of  many  hours  often  occur  and  it  has  not  been  at  all  unusual  for  the 
ambulance  not  to  arrive  until  the  next  day  after  the^call  was  sent  in.   One  of 

*  Note — It  is  understood  that  a  new  ambulance  has  recently  been  purcnased  for  City  Hospital. 


962  Hospital  and  Health  Survey 

the  hospitals  reported  a  case  of  pneumonia,  for  which  the  City  Hospital  was 
asked  to  send  an  ambulance  on  the  18th  of  the  month.  The  ambulance 
was  promised  for  the  20th  but  never  came  at  all.  In  the  case  of  contagious 
diseases,  which  can  only  be  received  at  City  Hospital,  and  for  which  the  City 
Hospital  ambulance  is  the  only  logical  and  suitable  means  of  transportation 
available,  such  a  delay  means  unnecessary  exposure  of  other  persons,  espe- 
cially dangerous  in  the  crowded  homes  and  lodging  houses  from  which  the 
City  Hospital  patients  are  apt  to  come.  It  is  our  opinion  that  at  least  two 
more  ambulances  should  be  provided  for  transporting  contagious  cases,  so 
that  all  these  cases  may  be  cared  for  by  the  City  Hospital's  own  ambulances. 
It  is  also  felt  that  twenty-four  hour  service  should  be  provided  by  the  City 
Hospital  for  contagious  cases.  With  the  transportation  of  contagious  pa- 
tients concentrated  under  the  control  of  City  Hospital,  the  hazard  of  poorly 
disinfected  ambulances,  such  as  at  present  exists,  could  be  obviated. 

Inasmuch  as  a  patient  for  whom  an  ambulance  is  called  is  often  seriously 
ill  or  injured,  ambulance  service  must  mean  more  than  mere  transportation 
from  one  place  to  another.  An  injured  man  may  have  to  be  carried  from 
his  house  to  the  ambulance.  A  person  hurt  in  a  street  accident  may  need 
some  form  of  first  aid  in  order  to  save  his  life.  A  case  of  acute  illness  needs 
to  be  made  comfortable  for  the  ride  to  the  hospital,  and  in  winter  needs  to 
be  sheltered  adequately  from  the  cold.  In  case  of  contagious  disease,  the 
ambulance  must  be  disinfected  in  order  to  protect  the  next  patient  usingfit. 

These  requisites  of  efficient  ambulance  service  are  met,  when  met  at  all 
in  Cleveland,  in  varying  degrees. 

The  Police  Emergency  cars  carry  the  driver  and  one  other  policeman" 
The  City  Hospital  ambulance  sends  someone  with  the  driver,  if  the  patient 
must  be  carried.  One  undertaking  firm  which  cares  for  many  of  this  class 
of  cases  sends  only  the  driver  of  the  car. 

Training  of  the  ambulance  crews  of  the  police  force  in  first  aid  and  the 
proper  care  of  patients  on  their  way  to  the  hospital,  has  not  been  so  com- 
plete and  adequate  as  is  desirable.  A  lecture  on  first  aid  is  given  by  a  physi- 
cian at  each  district,  and  instruction  is  given  in  the  use  of  the  pulmotor.  A 
few  years  ago  lectures  and  demonstrations  were  given  by  a  representative  of 
the  Life  Saving  Corps  of  the  Red  Cross.  Comment  has  come  to  the  Survey 
of  the  kindness  of  the  police  who  serve  with  the  ambulances,  but  more  than 
kindness  is  needed  to  give  first  aid  treatment  in  case  of  sun-stroke  or  suffo- 
cation. Skill  and  definite  training  are  necessary.  The  policemen  assigned 
to  ambulance  service  should  be  required  to  pass  a  thorough  course  in  first 
aid,  consisting  of  both  theory  and  practice.  The  provision  of  an  adequate 
emergency  kit  for  each  ambulance  would  seem  imperative,  yet  the  police 
patrols  are  provided  with  only  tourniquets,  rubber  gloves  and  handcuffs, 
and  the  City  Hospital  ambulance  had  no  first  aid  equipment  at  all.  This 
absence  of  first  aid  equipment  is  not  excusable,  and  should  be  remedied  with- 
out delay. 


Hospitals  and  Dispensaries  963 

At  present  there  is  no  continuous  assignment  of  members  of  the  police 
force  to  the  ambulance  service,  so  that  a  man  with  proficiency  gained  by 
experience  (in  lieu  of  training)  may  be  replaced  by  one  to  whom  the  simplest 
matters  of  emergency  treatment  are  unknown. 

No  matter  what  the  ailment  of  the  patient  may  be,  the  ride  to  the  hos- 
pital needs  to  be  made  as  copifortable  as  possible.  The  following  incident, 
similar  to  many  which  have  come  to  the  attention  of  the  Survey,  was  reported 
from  the  personal  observation  of  a  member  of  the  Survey  staff,  on  one  day 
during  the  winter.  The  Police  Emergency  was  drawn  up  in  front  of  a  store 
on  lower  Euclid  Avenue,  and  a  shivering,  pallid  woman  in  a  semi-conscious 
state  was  carried  out  and  placed  on  the  hard,  unpillowed  leather  shelf  of  the 
ambulance.  There  was  no  blanket  to  protect  the  woman  from  the  cold 
northeast  wind,  and  her  husband  covered  her  with  his  coat. 

The  type  of  ambulance  used  by  the  police  department  is  uncovered  at 
the  end  and  the  cars  are  very  unsuitable  for  cases  of  serious  illness,  especially 
for  patients  with  respiratory  disease.  The  City  Hospital  ambulance,  how- 
ever, is  a  closed  car  with  a  stretcher. 

The  Animal  Protective  League  operates  two  ambulance  trucks  for  the 
transportation  of  dogs,  and  was  at  the  time  of  the  study  having  another 
one  made.  Their  ambulances  are  fitted  with  adjustable  cages.  The 
interiors  of  the  cars  are  painted,  and  the  cars  are  washed  out  with  hot 
water  to  keep  them  in  a  clean  and  sanitary  condition.  In  winter  the  exterior 
wire  sides  are  covered  with  regulation  side  curtains.  The  humane  care 
of  dogs  is  a  matter  which  should  be  r>f  concern  to  every  person,  but  it  is  cer- 
tainly only  reasonable  to  insist  that  at  least  the  same  degree  of  humane  care 
be  rendered  to  human  patients  who  through  illness  or  accident  are  forced  to 
use  an  ambulance. 

... 
The  matter  of  disinfecting  an  ambulance  which  has  carried  a  patient  suf- 
fering from  contagious  disease,  is  one  of  importance.  Some  provision  is 
made  for  disinfecting  the  police  emergency  cars  by  formaldehyde  spray,  but 
conference  with  the  policemen  in  charge  of  these  cars  convinced  the  investi- 
gator that  very  little  real  disinfection  was  done.  Disinfection  of  the  City 
Hospital  ambulance  by  wiping  out  with  cloths  moistened  in  creolin  solution, 
and  change  of  pillow  case  and  blankets,  is  carried  out  on  return  from  trans- 
porting a  case  of  contagious  disease  only  when  the  case  next  to  be  called  for 
is  one  of  a  different  contagious  disease.  From  numerous  complaints  by  phy- 
sicians it  would  seem  that  undertakers  often  fail  to*  make  any  provision  for 
disinfection,  although  no  data  on  this  matter  were  obtained. 

One  thing  which  has  impressed  itself  most  forcibly  upon  the  Survey,  staff 
is  the  general  unwillingness  of  the  dependent  sick  to  use  the  Police  Emer- 
gancy  ambulance.  Well-to-do  patients  can  of  course,  afford  to  pay  the  fee 
charged  for  the  use  of  undertakers'  cars.  Innumerable  cases  were  found 
however,  where  patients  who  could  ill  afford  the  five  or  ten  dollars,  summoned 
the  private  ambulance  rather  than  endure  the  stigma  of  riding  in  the  police 
emergency.     It  must  be  remembered  that  to  all  practical  appearances  there 


964  Hospital  and  Health  Survey 

is  no  distinction  between  the  sick  man  in  the  police  emergency  and  the  man 
who  has  been  engaged  in  a  street  fight  or  some  less  commendable  pursuit. 
Natural  pride  and  self-respect  resent  such  a  method  of  transportation  in 
case  of  sickness  or  injury,  and  this  feeling  of  resentment  is  justifiable.  Cer- 
tainly a  more  dignified  and  considerate  method  of  conveying  a  patient  to 
the  hospital  needs  to  be  provided.  On  the  other  hand,  it  seems  just  as 
unfortunate  that  an  undertaker's  wagon  should  be  used  for  carrying  patients. 

No  ambulance  service  is  provided  for  taking  patients  to  Warrensville 
Infirmary  or,  in  case  a  contagious  disease  develops  there,  for  removing  the 
patient  to  City  Hospital.  In  the  latter  case  a  delivery  truck  is  used,  an 
arrangement  hardly  to  the  credit  of  the  city  of  Cleveland. 

It  is  believed  by  the  Survey  that  at  least  the  Cleveland  hospitals  main- 
taining over  200  beds  should  provide  their  own  ambulances,  and  that  the 
smaller  hospitals  might  combine  in  some  manner  under  the  Hospital  Coun- 
cil. In  order  to  maintain  such  a  system  of  ambulance  service  in  a  satisfac- 
tory manner,  it  is  necessary  to  have  some  central  organization.  In  Cleve- 
land, so  long  as  the  present  police  emergency  ambulances  will  doubtless 
remain  in  use  for  some  time,  even  though  individual  hospital  ambulances  are 
provided,  it  would  doubtless  be  best  to  retain  the  present  central  call  bureau 
under  the  jurisdiction  of  the  police  department,  assigning  an  emergency  dis- 
trict to  each  hospital  providing  such  service.  The  method  of  handling  ambu- 
lance calls  used  in  New  York  City  may  be  taken  as  the  basis  of  a  system  for 
Cleveland.  In  New  York  the  city  is  districted  for  emergency  ambulance 
service  and  there  is  a  central  bureau  to  which  all  emergency  calls  are  made. 
This  central  bureau  is  at  all  times  informed  of  the  movements  of  each  ambu- 
lance, whether  it  has  gone  for  a  patient,  or  whether  it  is  available  for  use  on 
a  call.  When  an  emergency  call  is  received  it  is  relayed  to  the  proper  district 
office.  With  a  little  modification  the  present  central  call  bureau  of  the 
Cleveland  Police  Department  could  be  adapted  for  the  use  of  an  efficient 
city -wide  ambulance  system. 

The  following  recommendations  are  considered  essential  to  the  improve- 
ment of  the  ambulance  service  of  Cleveland: 


RECOMMEND  A  TIONS 

The  police  patrol  wagons  should  be  replaced  by  ambulances  for  use  in  emergency 
work,  and  the  use  of  police  patrol  wagons  for  ambulance  transportation  should  be  dis- 
continued as  rapidly  as  possible. 

Each  ambulance  should  be  provided  with  a  stretcher,  blankets  and  ordinary  first  aid 
equipment,  including  a  Thomas  splint. 

At  least  four  such  cars  should  be  provided  and  stationed  in  appropriate  sections  of 
the  city. 

The  policemen  assigned  to  ambulance  service  should  be  required  to  pass  a  thorough 
course  in  first  aid,  consisting  of  both  theory  and  practice.     This  instruction  should  be 


Hospitals  and  Dispensaries  965 

under  the  direction  of  the  Division  of  Health.     Assignment  to  the  ambulance  branch 
of  the  police  service  should  be  continuous. 

At  least  two  more  ambulances  should  be  provided  at  the  City  Hospital  to  be  used 
for  transportation  of  contagious  cases  from  all  parts  of  the  city  to  the  City  Hospital,  and 
for  transferring  cases  to  and  from  Warrensville  Infirmary  and  Sanatorium. 

Twenty-four  hour  service  should  be  provided  by  the  City  Hospital  for  the  trans- 
portation of  contagious  cases. 

Hospitals  of  over  200  beds  should  provide  their  own  ambulance  service,  smaller  hos- 
pitals combining  with  one  another  under  the  Hospital  Council  to  provide  such  service. 
The  larger  hospitals  also  might  find  it  advantageous  to  come  into  some  such  joint  scheme. 

As  ambulance  service  is  provided  by  individual  hospitals,  an  agreement  should  be 
reached  with  the  Chief  of  Police  by  which  an  emergency  district  would  be  assigned  to  each 
hospital  providing  such  service. 

The  existing  centralized  system  of  calling  for  ambulances  at  the  Police  Information 
Bureau  should  be  continued  for  all  emergency  work. 

M     The  hospitals  and  public  health  agencies  should  discontinue  the  use  of  undertakers' 
invalid  carriages  for  ambulance  service. 


966  Hospital  and  Health  Survey 

V.      Hospital  and  Dispensary  Planning 

COMMUNITY  PLANNING 

From  the  standpoint  of  the  community,  hospitals  and  dispensaries  in 
Cleveland  have  been  planted,  rather  than  planned — planted  each  by  itself 
instead  of  being  planned  as  part  of  a  community  scheme  for  organized  medi- 
cal service. 

■y 
The  hospitals  thus  planted  have  grown,  but  have  not  grown  fast  enough 
to  keep  pace  with  the  development  of  the  city.  This  is  even  more  true  of 
the  dispensaries,  the  starved  children  of  the  hospitals.  The  outstanding, 
almost  tragic,  fact  in  the  situation  of  Cleveland  is  the  shortage  of  1,500  beds 
below  present  community  needs, .  and  the  deficiency  in  dispensary  service, 
which  at  present  is  not  more  than  one-third  of  the  needed  amount. 

These  major  needs  are  a  challenge  to  the  courage  and  resources  of  a  pro- 
gressive, self-confident  city  such  as  Cleveland.  The  passage  of  the  City 
Hospital  Bond  Issue  during  the  spring  of  1920  for  $3,500,000  gives  assurance 
that  when  the  necessary  steps  of  making  plans,  selling  bonds  and  putting  up 
buildings  have  been  taken,  at  least  one-third,  or  possibly  half,  of  the  needed 
1,500  beds  will  be  provided. 

It  was  originally  expected  that  the  $3,500,000  would  be  sufficient  to  con- 
struct 900  beds  and  a  dispensary,  tearing  down  the  present  psychopathic 
building  of  200  beds,  which  is  unfit  for  hospital  use;  and  thus  making  a  net 
addition  of  700  beds.  The  City  Hospital  would  then  have  practically  1,500 
beds,  and  it  should  have  this  number  as  soon  as  possible.  Since  the  figure 
$3,500,000  was  decided  upon  by  the  authorities,  building  costs  have  continued 
to  rise,  and  (while  the  future  course  of  prices  cannot  safely  be  predicted)  it 
is  probable  that  the  sum  will  be  insufficient  to  build  any  such  number  as  900 
beds,  besides  a  dispensary  and  necessary  enlargements  or  improvements  in 
nurses'  home,  power  plant,  kitchen,  etc.  The  present  city  administration 
should  proceed  as  rapidly  as  possible  with  plans  and  construction,  making 
the  $3,500,000  go  as  far  as  it  can,  and  all  public  officials  and  private  persons 
who  have  the  hospital  interest  of  the  city  at  heart  should  continue  their  efforts 
until  the  City  Hospital  has  reached  the  needed  size. 

Privately  supported  hospitals  must  expect  to  provide  750  to  900  beds  of 
the  needed  1,500,  as  soon  as  possible,  and  also  the  dispensaries,  as  outlined 
in  the  discussion  of  that  subject.  An  expenditure  of  probably  $12,000,000 
for  buildings  must  be  faced  by  the  people  of  greater  Cleveland  during  the  next 
few  years.*  This  figure  does  not  include  such  special  provisions  for  research 
and  medical  teaching  as  may  be  provided  in  connection  with  the  University 
Hospital.  Of  the  $12,000,000  it  may  be  expected  that  two-thirds,  or  a  little 
less,  will  have  to  be  provided  by  private  gifts,  and  about  one-third,  or  some- 
what more,  by  the  municipality. 

*This  sum  includes  $3,500,000  bond  issue.  At  the  time  of  concluding  the  Survey  the  bonds  had  been 
authorized  but  not  marketed. 


Hospitals  and  Dispensaries  967 


In  one  of  the  striking  financial  "campaigns"  of  recent  years,  the  Jewish 
Community  of  New  York  City,  with  a  population  only  slightly  more  than 
the  total  population  of  Greater  Cleveland,  raised  more  than  $7,000,000  for 
building  funds  for  its  various  institutions.  Cleveland  has  let  its  population 
grow  faster  than  it  has  permitted  its  hospitals  to  grow.  Atonement  for  the 
neglect  of  yesterday  can  only  be  made  by  dipping  more  deeply  into  the  pocket 
today.     Delay  means  only  the  incurring  of  still  heavier  future  obligations. 

It  is  greatly  to  be  desired  that  in  securing  these  building  funds  Cleveland 
shall  pursue  the  policy  already  so  finely  established  through  the  Welfare 
Federation  in  raising  annual  expenses.  Joint  campaigns  for  hospital  building 
funds  are  the  desirable  method.  Otherwise  Cleveland  will|be  weary  with 
one  hospital  "campaign"  following  another,  with  the  almost  inevitable 
result  that  those  which  happen  to  have  been  unable  to  make  campaigns  first 
will  suffer,  and  the  response  will  be  influenced  more  largely  by  chance  than 
by  relative  need  or  merit.  What  is  of  even  more  importance  is  that  balanced 
development  will  be  less  likely,  because  joint  campaigning  implies  inFa  con- 
siderable measure  joint  planning,  the  mutual  adjustment  of  plans^to  the 
broader  needs  of  the  community. 

It  is  true  that  the  present  year,  1920,  does  not  seem  a  propitious  one  for 
a  large  financial  "drive"  such  as  this  building  fund  campaign  would  have 
to  be.  There  are  just  two  practical  recommendations  for  those  who  ought 
to  voice  the  need  and  lead  the  campaign  to  meet  it:  conviction  and  courage. 
There  must  be  profound  belief  in  the  urgency  of  the  need  for  more  hospital 
beds  and  more  dispensaries,  and  firm  determination  to  meet  this  need  at 
the  earliest  possible  date. 

Projected  Enlargement 

The  Survey  found  that  a  number  of  Cleveland  hospitals  had  made  plans 
for  expansion.     Three  notable  examples  are  the  following: 

The  project  of  Lakeside  Hospital  to  move  from  its  present  site  near 
East  Twelfth  Street  and  Lakeside  Avenue,  to  Wade  Park,  enlarging  its 
capacity  from  289  beds  to  500  beds.  In  connection  with  this  is  to  be  men- 
tioned the  desire  to  move  Maternity  Hospital  to  the  same  area,  and  to  enlarge 
it  to  100  beds,  as  a  part  of  the  University  Hospital  group;  and,  the  building 
of  a  hospital  of  150  beds  for  babies  and  children,  as  part  of  the  same  group. 
The  total  for  the  group  is  750  beds,  making  a  net  increase  over  present  pro- 
visions in  the  same  group  of  institutions  of  400  beds. 

The  project  of  St.  Luke's,  to  move  from  its  present  site  on  Carnegie 
Avenue  to  Ambler  Heights,  and  to  enlarge  from  its  present  capacity  of  139 
beds  to  300  beds,  a  net  addition  of  161  beds,  or,  if  the  present  hospital  were 
retained  and  used  for  an  enlarged  dispensary  and  an  industrial  hospital  of 
perhaps  100  beds,  a  net  addition  of  about  250  beds. 

The  project  of  Huron  Road  Hospital  to  move  from  its  present  site  on 
Huron  Road,  to  Ansel  Road  and  Wade  Park,  enlarging  its  present  capacity 
of  84  beds  to  250  beds,  a  net  addition  of  166  beds. 


968  Hospital  and  Health  Survey 


The  plan  of  Lutheran  Hospital  to  enlarge  from  50  to  100  beds  has  already 
been  put  before  the  public  in  a  campaign  for  the  needed  funds. 

A  number  of  other  hospitals  have  stated  to  the  Survey  in  more  or  less 
specific  form  their  desires  or  projects  for  expansion.  It  will  be  observed 
that  on  the  minimum  basis  of  calculation  the  projects  of  Lakeside,  Maternity, 
the  new  Babies'  and  Children's  Hospital,  Huron  Road  and  St.  Luke's  would 
together  bring  Ja  net  increase  of  727  beds  minimum,  or  816  beds  maximum. 
In  other  words,  these  projects  alone,  if  carried  out,  would  provide  most  of 
the  900  beds  which  must  come  from  private  funds.  It  is  to  be  desired,  how- 
ever, if  a  joint  campaign  for  building  can  be  organized  and  successfully 
accomplished,  that  the  legitimate  desires  of  some  of  the  small  institutions  be 
recognized.  It  is  particularly  important  that  if  funds  cannot  be  asked  for  or 
secured  sufficient  to  provide  for  the  total  amount  required  for  the  needs  of 
all  the  institutions,  that  some  of  the  smaller  hospitals  whose  present  buildings 
and  equipment  are  now  notably  inadequate,  shall  be  allotted  sufficient  amounts 
to  enable  them  to  make  needed  changes  or  improvements  of  a  permanent  or 
semi-permanent  nature,  even  if  their  substantial  program  of  enlargement 
must  be  postponed,  and  if  the  plans  for  the  three  largest  hospitals  have  to 
be  somewhat  curtailed.  For  example,  the  improvement  of  the  nurses'  home 
at  St.  Vincent's  or  the  provision  of  a  dispensary  at  St.  John's,  are  urgently 
required  by  present  needs  for  better  service,  irrespective  of  increase  in  the 
number  of  beds. 

In  the  rounding  out  of  Cleveland's  hospital  facilities  through  the  develop- 
ment of  specialties,  the  increase  of  service  to  children  is  the  most  urgent 
need  in  both  hospitals  and  dispensaries.  The  building  of  the  proposed  Babies' 
and  Children's  Hospital  is  perhaps  the  most  greatly  needed  of  Cleveland's 
hospital  facilities,  after  the  enlargement  of  the  City  Hospital. 

There  is  need  of  enlargement  of  facilities  for  maternity  care,  and  the  pro- 
gram of  Maternity  Hospital  to  increase  its  size  from  60  to  100  beds  is  approved. 
This,  however,  is  not  so  urgent  as  a  number  of  other  needs,  such  as  for  chil- 
dren's beds,  for  an  eye  and  ear  hospital,  or  for  the  improvement  in  the  plants 
and  nurses'  homes  of  several  other  institutions,  such  as  St.  Vincent's,  St. 
Alexis,  etc. 

In  the  case  of  diseases  of  the  eye,  ear,  nose,  and  throat,  the  deficiencies 
in  Cleveland,  as  pointed  out  in  the  early  part  of  this  Report,  are  unusually 
serious.  Many  other  cities  have  found  it  desirable  to  establish  eye  and  ear 
hospitals.  New  York  provides  608  beds;  Boston,  219;  Baltimore,  153; 
Portland,  Maine,  100;  Washington,  94;  Philadelphia,  58;  Pittsburgh,  40;  and 
Chicago,  32.  In  Cleveland  one  hospital  only  (Lakeside)  makes  any  special 
reservation  of  beds  for  eye  cases.  Six  hospitals  maintain  an  ear,  nose,  and 
throat  service.  There  is  no  throat  ward  in  the  city.  There  are  cared  for  in 
hospitals  and  dispensaries  a  relatively  small  portion  of  the  eye,  ear,  nose, 
and  throat  work  required  by  a  population  as  large  as  that  of  Cleveland  and 
its  vicinity.  No  center  exists  for  the  training  of  physicians  and  nurses  in 
these  specialties.  There  are  exceedingly  numerous  industrial  eye  injuries. 
All  but  one  of  the  twelve  oculists  who  responded  to  the  Survey's  letter  of 


Hospitals  and  Dispensaries  969 

inquiry  stated  that  industrial  eye  injuries  came  to  them  with  evidences  of 
having  been  mishandled. 

Of  the  545  persons  in  the  city  known  as  totally  blind,  306  cases  may  be 
considered  as  due  to  preventable  diseases  or  injuries.  In  addition  to  this 
number,  121  cases  are  to  be  classed  as  curable. 

It  is  therefore  recommended  that  beds  to  the  number  of  100  be  established 
for  eye,  ear,  nose,  and  throat  cases;  these  beds  to  be  maintained  preferably 
as  a  branch  of  an  existing  general  hospital,  or,  if  established  as  a  separate 
hospital,  to  be  in  close  cooperation  with  a  general  hospital,  in  order  to  secure 
the  most  economical  administration  and  the  mutual  advantages  of  coopera- 
tion between  the  staff  of  the  general  hospital  and  the  specialists  in  eye,  ear, 
nose,  and  throat.  It  is  essential  that  there  be  such  freedom  and  independ- 
ence for  the  eye,  ear,  nose,  and  throat  staff  as  to  enable  the  fullest  develop- 
ment of  the  special  facilities,  technic,  and  educational  opportunities,  and  if 
these  conditions  cannot  be  met  were  the  beds  to  be  part  of  a  general  hospital, 
the  beds  should  be  established  as  a  separate  hospital,  with  the  affiliation 
indicated. 

It  is  desirable  that  the  hundred  beds  be  divided  between  the  ear,  nose, 
and  throat  service,  and  the  eye  service,  in  the  proportion  of  three  to  two; 
and  that  there  be  maintained  a  dispensary  eye  clinic  and  a  dispensary  ear, 
nose,  and  throat  clinic,  in  connection  with  these  beds.  The  clinics  had  best 
be  parts  of.  a  general  dispensary,  but  in  any  case  the  hospital  staff  should 
have  direct  medical  control.  It  is  of  course  highly  important  that  the  eye, 
ear,  nose,  and  throat  beds  and  clinics  be  used  for  medical  teaching  purposes, 
under-graduate  and  post-graduate,  and  for  nurses.  It  would  be  well  that 
there  be  provision  among  the  institutions  affiliated  with  these  special  beds 
for  an  exchange  of  visiting  physicians  and  surgeons,  and  of  nurses  in  training. 

Provision  for  all  other  specialties,  such  as  orthopedics,  and  laryngology, 
should  be  made  by  the  development  of  services  in  general  hospitals,  with  an 
assigned  number  of  beds  and  with  possibly  the  addition  of  more  beds  or 
pavilions  at  a  future  date,  rather  than  by  the  construction  of  new  important 
specialized  hospitals.  The  special  hospital  has  a  place  during  the  period  of 
development  of  the  technic  of  a  specialty;  but  the  permanent  provision  of 
hospital  facilities  in  special  branches  is  better  and  more  economically  made 
by  divisions  of  general  hospitals. 

Locations  and  Re-Locations 

The  study  made  by  the  Survey  of  the  locations  and  inter-relations  of 
hospitals  in  Cleveland  has  led  to  approval  of  the  plans  of  Lakeside,  Huron 
Road,  and  St.  Luke's  hospitals  to  move  from  downtown  locations  to  sites 
in  the  eastern  part  of  the  city,  in  or  near  Wade  Park.  Prevailing  winds  in 
Cleveland  are  from  the  west,  and  sites  in  the  eastern  part  of  the  city  will 
continue  to  be  dirtier  than  locations  on  the  western  edge,  until  Cleveland 
deals  effectively  with  its  obnoxious  coal  smoke.  It  must  be  pointed  out, 
however,  that  the  moving-out  of  these  hospitals  and  the  closing  of  St.  Clair 


970  Hospital  and  Health  Survey 

Hospital,  which  the  Survey  has  recommended,  will  leave  the  central  portion 
of  the  city  practically  unprovided  with  local  hospital  facilities.  With  ade- 
quate ambulance  service,  such  as  Cleveland  should  demand  and  secure  (see 
discussion  of  this  subject),  location  will  be  rendered  a  secondary  factor  in  a 
large  proportion  of  hospital  cases,  yet  the  tremendous  volume  of  hospital 
cases  arising  out  of  the  downtown  area  cannot  but  require  some  local  pro- 
vision. 

■j 

It  will  be  necessary  to  retain  either  at  Huron  Road  or  at  Lakeside,  or  in 
perhaps  a  new  hospital,  from  thirty  to  fifty  beds,  preferably  affiliated  with  a 
larger  out-lying  institution  so  as  to  secure  the  advantages  of  lowered  cost 
and  better  medical  service.  It  would  be  more  economical  if  the  present 
site  and  part  of  the  present  buildings  of  Lakeside  or  Huron  Road  were  utilized 
for  this  purpose  instead  of  requiring  new  construction. 

As  outlined  in  the  section  on  the  downtown  dispensary,  this  downtown 
hospital  should  be  part  of  the  same  plant  as  the  new  proposed  downtown 
dispensary. 

In  the  chapter  on  dispensaries  and  in  the  chapters  just  preceding,  the 
need  for  the  development  of  several  additional  dispensaries,  particularly  on 
the  west  and  south  sides  was  pointed  out,  and  the  particular  institutions 
named. 

All  of  these  points  regarding  the  location  of  hospitals  and  dispensaries 
and  their  inter-relation  need  to  be  thought  out  as  part  of  a  comprehensive 
plan  for  providing  general  service  to  the  city  as  a  whole,  and  also  local  facili- 
ties of  various  kinds,  readily  accessible  to  each  district.  In  previous  sections 
of  the  report  it  has  been  brought  out  that  certain  of  the  larger  hospitals  have 
a  wide  range,  drawing  patients  from  all  over  the  city  and  from  outside  the 
limits  of  Cleveland;  that  other  hospitals  are  largely  local  in  their  clientele. 
The  same  is  true  of  dispensaries,  some  being  city-wide  in  their  range,  others 
serving  few  patients  outside  of  one  general  section  of  the  city,  while  the  health 
centers  are  definitely  restricted  to  a  certain  comparatively  small  area,  as 
preventive  work  must  be  in  order  to  be  effective.  Certain  principles  under- 
lying community  planning  of  the  number  and  location  of  hospitals  and  dis- 
pensaries may  be  formulated  as  follows,  as  the  conclusion  of  this  section. 

Principles  of  Community  Plan 

There  should  be  a  small  number  of  what  may  be  called  major  hospitals 
and  dispensaries,  equipped  with  everything  in  the  way  of  modern  diagnostic 
and  therapeutic  equipment.  These  major  hospitals  and  dispensaries  are 
expected  to  be  city-wide  in  their  range,  and  to  serve  particularly  for  receiving 
difficult  cases  from  within  and  outside  the  city,  for  consultation  purposes 
and  for  diagnosis.  In  Cleveland  the  new  City  Hospital  with  its  dispensary 
should  serve  as  such  an  institution  for  the  west  side.  Lakeside,  in  its  present 
location  or  in  its  enlargement  as  part  of  the  University  group,  would  serve 
in  this  capacity  also.  Mount  Sinai  and  St.  Vincent's  may  be  mentioned 
also,  and  a  few  other  hospitals,  such  as  St.  Luke's,  may  develop  on  a  similar 


Hospitals  and  Dispensaries  971 

grade,  although  the  teaching  hospitals  and  dispensaries  should  be  the  dis- 
tinctive institutions  of  this  class  and  every  effort  should  be  made  to  render 
them  capable  of  measuring  up  to  this  responsibility  fully. 

What  may  be  called  the  district  hospital,  with  its  district  dispensary  or 
out-patient  department,  may  next  be  mentioned.  In  this  group  may  be  in- 
cluded the  bulk  of  the  hospitals  of  Cleveland,  the  range  of  which  is  not  strictly 
confined  to  a  given  district  but  which  are  more  local  in  character  and  which 
may  not  usually  expect  any  large  consultant  or  diagnostic  service  such  as 
would  go  with  the  teaching  institutions.  Somewhat  less  elaborate  and  ex- 
pensive equipment  and  a  less  high  degree  of  specialization  in  medical  organi- 
zation may  be  expected  in  this  group  of  institutions.  It  may  be  pointed  out 
that  such  institutions  fill  a  necessary  and  most  worthy  place  in  the  scheme 
of  hospital  and  dispensary  care  to  the  people  of  large  cities. 

Finally  come  the  health  centers,  primarily  preventive  in  their  activities. 
More  and  more  as  the  years  go  on,  various  therapeutic  services  of  the  simpler 
kind  need  to  be  located  in  as  many  neighborhoods  as  possible,  because  the 
more  localized  is  their  range,  the  more  intensively  and  effectively  can  they 
reach  100  per  cent,  of  the  population  with  a  message  of  hygiene,  with  period- 
ical examinations  for  the  detection  and  prevention  of  disease,  with  service 
for  the  prevention  of  infant  and  maternal  mortality,  the  discovery  and 
control  of  tuberculosis,  and  the  detection  of  remediable  physical  defects  of 
school  children. 

The  health  center  should  aim  to  reach  the  entire  population  of  its  district 
for  preventive  purposes,  sending  cases  in  which  defect  or  disease  is  discovered, 
either  to  the  family  physician  or  to  an  appropriate  dispensary  or  hospital,  or 
in  the  case  of  difficult  problems,  directly  to  the  major  institutions  for  diag- 
nosis. The  combination  of  some  of  the  simpler  forms  of  curative  work  with 
the  educational  and  preventive  services  is  a  necessary  development  of  the 
health  centers  of  the  future.  It  may  be  pointed  out  that  the  proposed  down- 
town dispensary  and  emergency  hospital  which  will  be  permanently  needed 
in  the  downtown  section  after  Lakeside  and  Huron  Road  move,  will  be  largely 
a  reference  center  for  preventive  as  well  as  for  diagnostic  and  curative  pur- 
poses. Particularly  in  a  city  like  Cleveland,  with  its  important  medical 
school,  the  institutions  doing  the  teaching  must  bear  the  primary  responsi- 
bility, in  hospitals  and  in  out-patient  clinics,  for  diagnostic  service  for  the 
patients  of  private  physicians  as  well  as  for  the  patients  who  cannot  afford  to 
pay  a  physician.  The  medical  profession  should  reap  the  benefit  of  the  de- 
velopment of  more  extensive  services  in  the  health  centers  and  in  the  dis- 
trict hospitals  and  dispensaries.  Appointments  therein  as  staff  or  auxiliary 
members  and  the  benefits  of  their  facilities  for  consultation  and  diagnosis, 
should  supply  the  most  serious  present  deficiencies  in  what  the  local  prac- 
titioner has  to  offer  his  patients. 

It  is  evident  that  the  danger  of  a  "community  plan"  is  that  it  leads  us 
to  glittering  generalities  merely.  But  it  ought  to  be  obvious  that  the  ab- 
sence of  a  community  plan  leads  to  anarchy.  Cleveland  has  taken  a  long 
step  away  from  the  state  of  anarchy  which  characterizes  the  medical  institu- 


972  Hospital  and  Health  Survey 

tions  of  most  large  cities,  through  its  Hospital  Council  and  its  Welfare  Federa- 
tion. Any  community  plan  which  exists  not  merely  on  paper  but  which  is 
a  living  thing  with  muscles  and  teeth,  requires  that  individual  institutions 
must  adapt  their  policies  and  programs  accordingly. 

Sacrifices  of  policies  or  programs  which  seem  desirable  and  legitimate 
from  the  standpoint  of  an  individual  institution  may  be  called  for  by  its 
proper  adjustment  to  larger  community  needs.  It  seems  hard,  at  times, 
to  expect  a  worthy  institution  to  say  "no"  to  the  eager  desire  of  its  staff  for 
a  program  of  expansion  which  a  community  Survey  shows  is  more  than  is 
required  by  the  institution's  district  or  by  the  particular  kind  of  need  which  it 
serves;  yet  at  times  such  negative  prescriptions  are  wise  and  necessary,  and 
should  be  self-imposed.  It  is  not  too  much  to  expect  of  the  hospitals  and 
dispensaries  of  Cleveland  that  they  have  a  community  plan.  It  is  not  too 
much  to  expect  that  they  abide  by  it,  living  not  as  bachelors  and  spinsters 
who  have  only  themselves  to  consider,  but  as  members  of  a  family  each  of 
whom  shares,  nourishes,  and  is  nourished  by  the  life  of  the  whole. 


Hospitals  and  Dispensaries  973 

INDIVIDUAL  HOSPITAL  PLANNING 

The  wise  planning  of  a  hospital's  policy  involves  at  least  four  elements: 

1.  Adaptation  of  the  work,  as  to  kinds  of  service  offered,  rates  charged,  etc., 
to  the  community,  the  district  and  the  hospital's  special  clientele. 

This  adaptation  should  be  based  on  knowledge,  perhaps  requiring  special 
study  of  the  social  as  well  as  the  medical  character  of  the  hospital  clientele, 
as  outlined  in  the  section  on  "The  Human  Problem  of  the  Hospital  Pa- 
tient". The  Cleveland  Hospital  and  Health  Survey  has  rendered  to  the 
governing  authority  of  each  hospital  in  the  Council  a  report,  the  recom- 
mendations of  which,  as  to  policy  and  administration,  are  the  result  of  such 
a  study.  Each  hospital  has  thus  had  a  cross  section  of  the  situation  and 
demands  of  19-20,  as  judged  by  the  Survey. 

2.  Periodical  Self-Surveys,  based  on  continuous  critical  observation  of  the 
institutions  work,  by  its  trustees,  staff  and  executive  officers,  and  fortified  by 
annuil  reports  and  special  studies.  As  urged  below,  annual  reports  should 
not  be  the  basis  for  annual  self-contemplation,  but  for  a  critical  review  and 
a  vigorous  effort  toward  better  service. 

3.  Long-range  planning  of  program.  Each  hospital  should  look  as  jar 
ahead  as  possible,  studying  out  its  present  and  future  needs,  (a)  as  to  kinds  of 
service  which  it  should  render  and  (6)  as  to  the  building,  equipment,  organiza- 
tion, and  personnel  which  it  needs  to  have  in  order  to  render  these  services. 

Not  a  few  hospitals  of  Cleveland  are  suffering  today  because  no  com- 
prehensive plan  was  made  in  the  past,  and  additions  have  been  made  to  hos- 
pital buildings  which  now  make  a  badly  balanced  plant.  Often  the  service 
buildings,  the  nurses'  home,  or  the  power  plant  were  not  provided  for  suffi- 
ciently when  additions  were  made  to  bed  capacity,  or  were  not  planned 
with  a  view  to  easy  enlargement  when  the  number  of  beds  should  be  in- 
creased. A  comprehensive  plan  which  may  be  many  years  in  realization 
will  prevent  one-sided  and  ill-judged  extensions  either  in  plant  or  in  branches 
of  service.  Expert  advice  and  assistance  could  be  provided  for  many  in- 
stitutions by  the  Hospital  Council  or  the  Welfare  Federation  in  connection 
with  this  long  range  planning  of  each  hospital,  although  of  course  in  case  of 
large  institutions,  or  where  extensive  future  building  plans  are  involved,  the 
special  aid  of  a  hospital  architect  or  consultant  may  be  desirable. 

h.  Annual  Reports  to  the  Welfare  Federation  and  to  the  Public. 

Until  recently,  each  hospital  in  Cleveland,  as  elsewhere,  depended  on  its 
own  particular  list  of  financial  supporters.  Each  hospital  usually  prepared 
its  annual  report  more  or  less  especially  designed  to  express  that  quality  of 
gratitude  which  has  been  described  as  a  "lively  expectation  of  favors  yet  to 
come."  The  situation  was  radically  changed  when  there  came  about  joint 
financing  through  the  Community  Fund.  The  individual  hospital  no  longer 
makes  a  direct  public  appeal  for  its  own  support.  Such  joint  financing  is 
highly  desirable  on  the  whole,  but  certain  minor  defects  or  difficulties  must 


974  Hospital  and  Health  Survey 

be  guarded  against.  One  of  these  is  ■ ,  diminished  incentive  t3  prepare  an 
annual  report.  It  is  true  that  under  such  a  system  as  that  of  the  Welfare 
Federation,  each  institution  must  present  its  budget  and  the  financial  and 
service  data  required  by  the  Welfare  Federation  so  that  the  appropriating 
committee  shall  be  in  a  position  to  reach  a  wise  decision.  Nevertheless, 
there  is  no  longer  the  same  sense  of  direct  relationship  with  the  public,  and  a 
more  or  less  definite  public  at  that.  After  all,  one  of  the  great  values  of 
periodical  reports  ought  to  be  the  stimulus  to  the  people  who  make  them 
(which  mere  compilations  of  financial  and  statistical  data  do  not  provide). 
Preparation  of  a  report  ought  to  mean  the  formulation  of  fairly  definite 
ideas  about  the  work  and  needs  of  the  matter  reported  on.  It  will  mean 
this  if  the  basal  scheme  of  the  report  is  properly  designed. 

Recognizing  this,  the  Welfare  Federation  and  the  Hospital  Council 
should  expect  their  member  institutions  to  render  not  only  the  necessary 
statistical  and  financial  data  but  also  real  reports  to  the  public.  The  future 
of  joint  financing  depends  upon  maintaining  active  public  interest  in  the 
work  to  be  financed.  There  must  be  meat  upon  which  this  interest  may 
feed.     Concrete  facts  are  the  basis. 

Theje  should  be  three  types  of  reports  furnished  to  the  public  either  di- 
rectly or  through  the  Welfare  Federation  or  the  Hospital  Council : 

1.  Summary  report  of  hospital  and  dispensary  work  in  Cleveland,  taken  as 
a  whole,  including  the  elementary  data  showing  bulk  and  general  types  of  service 
rendered,  income  and  expenses. 

This  should  be  prepared  under  the  auspices  of  the  Hospital  Council  and 
published  by  the  Welfare  Federation.  A  form  for  such  a  report  is  suggested 
and  may  be  found  in  the  appendix,  Table  IX.  This  may  well  be  compared 
with  the  Summary  Annual  Report  of  the  United  Hospital  Fund  of  New  York 
City,  the  pioueer  undertaking  of  its  kind  in  this  country. 

2.  A  report  from  each  hospital  to  the  Hospital  Council  and  the  Welfare 
Federation,'  giving  the  technical  figures  not  only  of  bulk  and  general  types  of  work 
but  the  details  of  service  and  results;  of  cost  in  relation  to  units  of  service:  and 
of  income  and  its  various  sources. 

The  monthly  and  annual  report  forms  prepared  by  the  Hospital  Council 
for  the  use  of  its  members  have  served  a  highly  useful  purpose.  They  may 
be  slightly  developed  further  to  advantage,  and  should  be  made  uniform 
with  the  reports  required  by  the  Welfare  Federation.  The  Hospital  Council 
annual  report  form  is  believed  to  furnish  so  desirable  a  basis  that  no  other 
form  will  be  outlined  here.  It  is  suggested  that  the  form  might  be  somewhat 
smaller  and  easier  to  use  if  some  of  the  items  which  are  extended  over  many 
lines  were  put  into  more  condensed  and  tabular  form.  These  and  other  de- 
tails should  be  adjusted  so  far  as  possible  in  order  that  this  form  shall  be 
comparable  with  that  required  by  the  State  Department  of  Health.  Thus 
the  labor  of  filling  out  two  forms  will  be  reduced  to  a  minimum. 


Hospitals  and  Dispensaries  975 

It  is  recommended  that  the  following  items  be  included  in  the  report 
form: 

Percentage  of  bed  days  care  given  in  comparison  with  total  possible 
number  of  days  care  in  each  division  of  the  hospital,  and  for  the  hospital  as 
a  whole  (monthly  and  annual.)  The  extent  to  which  it  is  poLsib'e  to  sub- 
divide the  different  sections  of  the  hospital  will  depend  on  the  degree  to 
which  the  hospital  is  itself  sub-divided  into  buildings  or  separate  units,  and 
the  degree  to  which  groups  of  wards  or  rooms  are  definitely  assigned  to  par- 
ticular services  or  classes  of  patients. 

The  number  of  visits  ^and  number  of  new  patients  in  each  clinic  or 
division  of  the  dispensary  should  be  shown  as  well  as  the  figures  for  the  dis- 
pensary as  a  whole;  the  average  number  of  visits  per  patient  for  each,  and 
the  average  attendance  per  clinic  day.     Thus  in  tabular  form: 

Clinic  Report  for  Month  (or  Year)  for  Dispensary  of — 


Name  of     No.  of     No.  of  New  Av.  No.  of  Visits         No.  of  Av.  No.  of 

Clinic       Visits  Patients  per  Patient  Clinic  Days        Visits  per  Day 

Medical 

Surgical 

Pediatric % 

Eye 

Dermatological.— 

Etc 

Total 

If  evening  clinics  are  conducted  on  a  different  financial  basis  (pay  clinics) 
from  the  corresponding  day  clinic  these  should  be  shown  separately. 

The  cost  of  the  dispensary  and  the  income  from  its  operation  in  relation 
to'cost  should  be  shown.  Income  from  operation  may  well  be  classified  into 
admission  fees,  treatment  fees,  fees  for  medicines. 

As  soon  as  the  accountant  service  of  the  Welfare  Federation  (as  recom- 
mended in  the  sections  on  administration)  is  in  effective  operation,  all  hos- 
pitals would  be  in  a  position  to  show  the  costs  for  the  main  divisions  of 
their  work,  as  well  as  for  the  hospital  as  a  whole  (average  daily  per  capita) 
and  for  the  average  daily  cost  for  provisions  per  capita.  In  so  far  as  it  is  pos- 
sible to  state  relative  costs  for  private  room  and  for  ward  service,  this  should 
be  done. 

As  soon  as  possible  a  report  on  results  of  service  should  be  developed. 
The  usual  report  of  "condition  on  discharge"  as  "cured,"  "improved", 
"unimproved",  "died",  is  definite  only  in  the  last  item;  has  practically  no 
medical  or  social  value  and  is  not  worth  including  in  hospital  reports.     Real 


976  Hospital  and  Health  Survey 

reports  of  results  of  care  of  patients  can  develop  only  as  the  outcome  of  a 
real  follow-up  system.  As  individual  hospitals  develop  these,  a  summary 
report  of  results  of  care  should  be  included  in  the  annual  report  form.  It 
would  be  well  at  once  to  include  the  following  items  in  the  form  under  the 
heading : 

"Disposition  of  Patients  at  Discharge." 

Total  patients  discharged - 

Of  these,  patients  died  to  the  number  of.... 

Remainder , 

Disposition  of  these  as  follows : 

Private  Ward  or  Staff 

Patients  Patients 

No.     Per  cent.     No.     Per  cent. 

1.  Referred  to  home  under  care  of  private  physician 

2.  Referred  to  another  hospital 

3.  Referred  to  convalescent  home 

4.  Referred  to  dispensary  supervision 

5.  Referred  to  patient's  home  without  arrangement  as  to  care 

6.  Other  reference 

7.  Left  against  advice 

8.  Unknown  or  no  record ; 


Total 

The  use  of  such  data  showing  administrative  action  at  the  time  of  dis- 
charge will  be  a  definite  stimulus  toward  better  follow-up  and  convalescent 
care. 

3.  The  third  form  of  report  from  the  hospitals  should  be  not  statistical  but 
interpretative:  a  statement  of  progress  and  of  problems,  of  accomplishment  and 
of  needs. 

The  traditional  annual  report  has  done  this  in  a  measure  but  has  often 
been  written  by  committee  members  who  had  little  first-hand  contact  with 
the  facts,  or  very  slight  conception  of  what  should  be  said  except  thanks  to 
other  committee  members  and  to  staff  and  supporters,  so  that  it  largely 
failed  to  accomplish  any  real  purpose.  An  annual  report  should  be  built 
from  the  ground  up.  The  medical  executive  committee  and  the  head  of 
each  main  administrative  department  should  be  asked  to  turn  in  a  report 


Hospitals  and  Dispensaries  977 

for  their  several  fields  six  weeks  before  the  report  is  to  be  issued.  It  should 
be  expected  that  besides  certain  statistical  or  other  facts  relative  to  the 
work  of  the  department,  these  reports  shall  contain  a  summary  of  (a)  accom- 
plishments of  the  year — -items  felt  to  be  indications  of  progress;  (b)  present 
problems  and  needs;  (c)  definite  requests  and  recommendations  for  action. 
In  some  hospitals,  each  chief  of  a  medical,  surgical,  or  special  division,  the 
head  of  the  laboratory,  and  the  head  of  the  X-Ray  department  will  be  asked 
to  render  reports  as  well  as  the  medical  executive  committee. 

The  reports  from  the  head  of  the  nursing,  and  from  the  head  of  social 
service,  should  pass  through  the  training  school  committee  or  the  social  ser- 
vice committee,  respectively,  before  coming  to  the  superintendent  and  to 
the  trustees.  The  committee  may  write  its  own  report  if  desired,  but  in  any 
case  should  state  its  comment  upon  the  recommendations  presented  by  the 
executive. 

It  is  recognized  that  securing  reports  from  many  medical  and  depart- 
mental heads  is  not  always  easy  and  that  the  reports  are  not  always  well 
prepared  or  to  the  point.  Much  of  this  difficulty  has  been  due  to  failure  on 
the  part  of  the  Superintendent  or  trustees  to  give  to  those  writing  reports  a 
definite  idea  as  to  what  was  expected. 

The  superintendent's  report  to  the  trustees  should  be  a  real  survey  of 
the  hospital,  its  accomplishments,  problems  and  needs,  and  should  include 
recommendations.  Trustees  who  do  not  receive  that  type  of  report  either 
do  not  know  how  to  get,  or  do  not  get,  the  best  out  of  the  man  or  woman 
whom  they  employ  as  superintendent. 

On  the  basis  of  such  reports  from  their  executive  officer  and  their  depart- 
ments, and  of  conference  with  them,  the  trustees  should  be  in  a  position  to 
know  what  they  need  to  know  to  plan  the  coming  year's  policy  and  program, 
and  the  amount  of  money  they  need  to  secure.  The  reports  should  be  the 
basis  of  the  presentation  of  the  hospital's  needs  to  the  Welfare  Federation 
and  should  be  accessible  to  those  having  a  basis  for  definite  interest  therein. 

The  trustees  ought  not  to  have  to  prepare  a  detailed  report,  but  merely 
a  brief  statement  of  decisions  or  recommendations  for  which  the  other  re- 
ports are  the  foundation.  A  group  of  reports  thus  prepared  should  con- 
stitute a  real  annual  self-survey.  This  need  rarely  be  printed  as  a  whole. 
There  is  required  something  less  technical  for  a  published  report. 


Interpreting  Hospital  to  Public 

It  is  essential  from  the  standpoint  of  maintaining  the  interest  of  the  pub- 
lic in  a  hospital  and  dispensary  and  of  stimulating  boards  of  trustees  of  the 
institution  itself,  that  technical  facts  of  such  reports  be  interpreted  in  terms 
of  ordinary  items  of  interest  and  of  every-day  human  standards  of  health 
and  well-being.  This  is  not  usually  within  the  capacity  of  the  hospital  ad- 
ministrator or  trustee. 


978  Hospital  and  Health  Survey 

The  hospital  needs,  and  the  Welfare  Federation  should  furnish  each  hos- 
pital, the  service  of  a  publicity  expert,  just  as  it  provides  the  service  of  an 
accountant  for  the  technical  data.  The  publicity  man  would  help  the  hos- 
pital to  put  its  technical  facts  in  common  terms,  to  connect  them  with  ideas 
and  interests  which  the  average  man  readily  understands  and  appreciates. 

The  use  of  such  a  statement,  put  into  form  with  the  advice  of  the  pub- 
licity man,  would  be  partly  for  those  particularly  interested  in  the  hospital, 
and  partly  for  other  hospitals  and  the  general  public,  reached  through  the 
Welfare  Federation  and  the  press.  The  custom  of  presenting  reports  at  an 
annual  public  meeting  of  the  trustees  or  members  of  the  hospital  corporation 
is  useful  if  only  that  it  gives  to  reports  a  certain  news  value. 

Under  present  conditions  in  Cleveland,  the  trustees  of  hospitals  are 
freed  from  the  necessity  of  the  continuous  pursuit  of  the  vocation  of  honor- 
able begging,  the  most  characteristic  occupation  of  trustees  in  most  com- 
munities. They  may  ordinarily  concentrate  their  financial  efforts  within  a 
brief  period  of  the  year,  and  be  free  at  other  times  to  give  their  attention  to 
administration,  and  planning  for  the  hospital.  It  is  above  all,  important 
that  in  working  out  and  planning  the  present  and  future  policy  of  individual 
hospitals,  the  trustees,  the  staffs,  and  the  executive  officers  keep  always  be- 
fore them  the  conception  that  the  hospital  is  an  agent  for  service  to  the  com- 
munity, and  not  an  institution  with  all  its  roots  in  its  own  soil.  There  is 
marked  danger  that  those  who  work  within  the  four  walls  of  an  institution 
lose  touch  with  outside  interests  and  agencies,  and  develop  the  ingrowing 
rather  than  the  outlooking  mind.  This  danger  is  particularly  apparent  in 
such  a  highly  specialized  technical  service  as  that  of  a  hospital.  A  well- 
managed  dispensary  tends  to  assist  hospital  trustees,  staffs,  and  adminis- 
trators to  keep  in  touch  with  the  community,  because  a  dispensary  is  less 
rigid,  less  walled-in  than  a  hospital  proper,  and  helps  in  achieving  a  prac- 
tical combination  of  administrative  efficiency  with  human  adaptability. 
Hospitals  closely  connected  with  a  church  organization  appear  in  some  cities 
particularly  prone  to  be  over-institutionalized.  The  public  spirit  and  com- 
munity interest  manifested  by  such  hospitals  as  St.  Vincent's  and  St.  John's 
should  be  mentioned  as  notable  illustrations  of  a  different  point  of  view  in 
Cleveland.  Such  a  cooperative  organization  as  the  Cleveland  Hospital 
Council  has  undoubtedly  assisted  all  hospitals  to  think  in  terms  of  larger 
units  than  themselves. 


Hospitals  and  Dispensaries  979 


ORGANIZATION  TO  CARRY  OUT  PLANS 

Planning  for  individual  hospitals  and  planning  for  the  hospitals  and 
dispensaries  of  a  community  as  a  whole  will  yield  little  practical  result  unless 
there  is  community  organization  of  the  right  sort.  In  Cleveland  we  may 
classify  the  community  functions  and  organization  in  two  groups,  those 
under  public  auspices  (municipal  or  state)  and  those  under  private  auspices, 
affiliated  as  members  of  the  Welfare  Federation  and  the  Cleveland  Hospital 
Council. 

An  institution  dealing  with  so  serious  a  matter  as  treatment  of  illness 
has  a  responsibility  to  the  public  which  should  be  recognized  by  a  certain 
degree  of  public  supervision.  By  a  recent  law,  the  Department  of  Health 
of  the  State  of  Ohio  was  empowered  to  register,  define,  and  classify  all  hos- 
pitals and  dispensaries,  to  require  hospital  reports,  and  to  license  maternity 
hospitals.  It  is  deemed  desirable  that  these  public  supervisory  powers  be 
extended  as  follows: 

(a)  Every  hospital  and  dispensary  should  be  required  to  obtain  a  license 
to  operate  from  the  State  Department  of  Health.* 

(b)  Such  license  should  be  issued  for  a  term  of  one  year,  renewable  by 
the  Department. 

(c)  Licenses  should  be  revocable  for  cause,  provided  that  notice  of 
reasons  shall  be  given  in  advance  to  the  institution  and  also  an  opportunity 
for  a  public  hearing  when  requested. 

(d)  Hospitals  and  dispensaries  incorporated  as  charities  should  be 
licensed  without  fee  and  a  small  license  fee  should  be  charged  to  institutions 
which  are  incorporated  for  profit. 

(e)  Inspection  by  the  State  Department  of  Health  should  be  provided 
for  and  appropriation  made  for  a  staff  to  perform  this  work. 

The  State  Department  of  Health  should  be  empowered  to  outline  and 
prescribe  requirements  or  standards  under  which  licenses  should  be  issued 
and  under  which  hospitals  and  dispensaries  may  operate. 

The  administrative  powers  of  the  State  Department  of  Health  should  be 
exercised  by  this  Department  throughout  the  State,  except  in  chartered 
cities.  Such  cities  should  be  authorized  to  pass  laws  or  ordinances  (the  con- 
stitution provides  that  they  shall  not  be  inconsistent  with  the  existing  state 
laws)  and  to  administer  the  licensing  and  inspecting  powers  above  provided 
for  under  its  own  local  authority. 

*It  is  the  opinion  of  Doctor  Babcock,  who  has  collaborated  on  this  study,  that  this  is  an  undesirable 
administrative  responsibility  to  place  on  state  authorities. 


980  Hospital  and  Health  Survey 

The  State  Department  should  administer  the  law  directly  in  those  cities 
or  other  political  subdivisions  which  do  not  maintain  their  local  administra- 
tion under  their  own  auspices.  The  State  Department  of  Health  should  in 
all  cases  continue  to  receive  annual  reports  from  hospitals  and  dispensaries 
and  to  maintain  a  register  of  all  licensed  institutions.  No  chartered  city 
should  be  permitted  to  prescribe  or  tolerate  standards  for  the  maintenance 
or  licensing  of  hospitals  or  dispensaries  which  fall  below  those  prescribed  by 
the  State  Department  of  Health. 

If  there  were  no  other  reason  than  the  existence  in  Cleveland  of  a  num- 
ber of  commercial  hospitals,  this  would  be  sufficient  for  the  extension  of  the 
powers  of  the  state  and  the  administration  of  these  powers  in  Cleveland 
by  the  municipal  government.  The  inspection  made  by  the  Survey  of  the 
sixteen  institutions  not  members  of  the  Cleveland  Hospital  Council  revealed 
the  fact  that  while  a  few  are  of  the  public-service  class  and  a  few  others  are 
well  conducted  proprietary  institutions  giving  a  fair  standard  of  care  to  their 
patients,  the  remainder  are  utterly  unworthy  of  existence.  In  six  cases  no 
graduate  nursing  service  whatever  was  provided  for  the  sick  patients.  In 
more  than  one  instance,  the  buildings  were  dirty  and  the  patients  appeared 
to  be  physically  uncared  for. 

Proprietary  hospitals  have  a  legitimate  place,  but  making  a  profitable 
business  out  of  the  improper  care  of  the  sick  is  intolerable,  and  can  be  pre- 
vented only  by  public  authority.  The  State,  utilizing  as  proposed  the  ma- 
chinery of  the  city  government  in  the  larger  communities,  has  the  right  and 
duty  to  set  minimum  standards  to  which  every  institution  treating  the  sick 
shall  conform,  and  to  enforce  such  standards  through  appropriate  agents. 
Such  a  policy  does  not  mean  interference  in  hospital  management  by  the 
state  or  city,  or  public  regulation  of  hospitals  in  any  detailed  sense  of  the 
term.  'It  means  the  securing  of  such  facts  as  shall  enable  the  public  to  be 
protected  against  an  unworthy  and  improper  class  of  institution — leaving  the 
majority,  which  are  far  above  this  class,  free  to  conduct  themselves  as  they 
will. 

It  is  important  in  a  community  program  for  dealing  with  hospitals  and 
dispensaries,  that  the  municipal  agencies  caring  for  the  sick  shall  be  properly 
related  to  the  private  agencies,  and  this  has  been  notably  achieved  in  Cleve- 
land through  the  Hospital  Council.  The  City  Hospital  is  a  member,  as  well 
as  the  privately  supported  institutions. 

The  broader  interests  of  the  city  in  public  health  (in  which  the  hospitals 
are  also  concerned)  should  be  brought  into  closer  touch  with  private  agencies 
interested  in  such  subjects,  through  some  such  means  as  the  proposed  Cleve- 
land Public  Health  Association  (see  Part  II.).  In  the  opinion  of  the  Survey, 
the  relations  between  the  Welfare  Federation,  the  Cleveland  Hospital  Coun- 
cil, and  the  individual  institutions  should  be  somewhat  as  follows: 

Outlines  of  Community  Organization 

1.  It  is  the  function  of  the  Welfare  Federation  to  deal  with  questions  of 
general  policies  in  relation  to  large  groups  of  welfare  agencies  and  in  particu- 


Hospitals  and  Dispensaries  981 

lar  to  provide  machinery  for  joint  financing  and  suitable  apportionment  of 
funds  raised. 

It  is  highly  desirable  and  has  been  elsewhere  recommended  by  the  Survey 
(Part  II.)  that  the  Welfare  Federation  have  on  its  executive  staff  an  assistant 
to  its  general  director,  who  will  be  an  expert  in  the  health  field,  and  who 
will  be  able  to  advise  the  director  on  the  many  problems  in  this  field  to  which 
the  Federation  devotes  over  one  million  of  the  four  million  dollars  raised 
annually  by  the  Community  Fund. 

2.  Within  the  hospital  and  dispensary  field,  the  Hospital  Council  should 
outline  standards  for  hospitals  and  dispensaries,  covering  minimum  require- 
ments in: 

(a)  Organization  (board  of  trustees,  superintendent,  staff,  nursing,  etc.) 
for  hospitals  and  dispensaries. 

(b)  Medical  work  (examinations,  use  of  laboratories,  records,  internes, 
private  and  ward  patients). 

(c)  Finance  and  accounting. 

3.  Only  hospitals  complying  with  these  standards  should  be  admitted  or 
retained  as  members  of  the  Council. 

4.  Only  hospitals  in  the  Council  should  be  assisted  by  the  Federation. 

5.  Financial  support  by  the  Federation  should  be  on  the  basis  of  chari- 
table work,  which  should  be  taken  to  include  free  service  and  also  part-pay 
service,  rendered  in  hospital  beds  or  in  dispensary  clinics. 

6.  Appropriations  for  the  support  of  dispensary  work  should  be  separated 
from  those  of  hospital  work,  since  the  units  of  service  are  different. 

7.  Municipal  hospitals,  and  also  hospitals  not  doing  charitable  work  as 
above  defined  but  complying  with  the  standards,  may  be  members  of  the 
Council  and  the  Federation,  and  receive  the  benefits  of  such  membership 
(they  will  not  of  course  need  financial  aid) . 

Place  of  Hospital  Council 

The  Cleveland  Hospital  Council  has  been  of  such  great  value  to  Cleve- 
land and  indeed  to  the  state  and  the  country  that  too  much  emphasis  cannot 
be  laid  upon  the  importance  of  its  adequate  maintenance  and  development. 
It  has  brought  the  hospitals  of  the  city  together  for  cooperative  work,  and 
for  mutual  improvement  in  many  respects.  Advantageous  legislation  in 
connection  with  hospital  service  and  public  health  work  has  been  promoted 
by  the  influence  of  the  Council  and  by  the  activities  of  its  executive  secre- 
tary. Certain  of  the  technical  standards,  forms  of  report,  etc.,  as  outlined 
by  the  Council  have  been  made  use  of  by  institutions  and  by  official  bodies 
in  other  parts  of  the  United  States. 


982  Hospital  and  Health  Survey 

The  Central  Purchasing  Department  of  the  Council  has  been  and  is  a 
valuable  contribution  to  the  economy  of  hospital  administration.  The 
amount  of  purchasing  done  (for  hospitals  alone)  for  the  first  half  of  the  year 
1919  was  $90,890.89;  for  the  entire  year  of  1919,  $268,503.07;  and  for  the 
first  six  months  of  1920,  $222,278.97.  It  will  be  noticed  that  the  purchases 
for  the  first  half  of  1920  almost  equal  the  purchases  for  the  entire  year  of 
1919.  It  is  estimated  by  the  Department  that  there  has  been  a  saving  on 
the  large  purchases  for  the  first  half  of  1920  to  the  amount  of  $10,000.00, 
and  that  there  was  also  considerable  saving  on  the  small  purchases,  although 
no  definite  estimate  can  be  furnished  of  this. 

Consideration  should  be  given  to  the  transfer  of  the  Purchasing  Depart- 
ment from  the  auspices  of  the  Hospital  Council  to  those  of  the  Welfare  Fed- 
eration, in  order  that  the  range  of  service  of  the  Department  may  be  widened; 
or  the  Council  might  offer  the  services  of  the  Department  to  Federation 
organizations  which  are  not  members  of  the  Council. 

The  opportunities  for  service  by  the  Council  to  the  hospitals  of  Cleve- 
land are  increasing  steadily  in  proportion  as  the  hospitals  appreciate  more 
and  more  the  advantages  of  cooperative  activity  in  administrative  direc- 
tions, for  the  sake  of  economy  and  efficiency,  and  of  conferences  and  discus- 
sion for  more  effective  formulation  of  policies  concerning  hospital  service. 

The  development  of  a  dispensary  section  of  the  Hospital  Council  for 
purposes  of  improvement  of  dispensary  service  which  is  recognized  as  an 
urgent  need  throughout  the  city,  is  now  an  important  activity  wjiich  natur- 
ally belongs  within  the  general  scope  of  the  Cleveland  Hospital  Council. 

Almost  endless  opportunities  exist  for  service  to  hospitals  through  the 
expert  services  of  the  executive  staff  of  the  Council,  which  should  assist  the 
members  in  an  advisory  way  through  their  own  efforts  and  through  as- 
sembling information,  arranging  conferences,  securing  expert  advice  from  other 
sources,  etc.  Many  of  the  recommendations  made  by  the  Survey  to  indi- 
vidual hospitals,  particularly  those  of  moderate  or  small  size,  will  doubtless 
cause  these  hospitals  to  appeal  to  the  Hospital  Council  for  advice  in  helping 
them  to  work  out  details  of  such  recommendations  as  are  approved  in  gen- 
eral by  the  hospital  trustees.  The  interest  of  the  hospitals  in  legislation 
will  continue  to  call  for  some  activity  in  this  direction  on  their  part  each 
season. 

The  organization  and  staff  of  the  Hospital  Council  does  not  appear  ade- 
quate at  present  to  meet  these  demands,  but  it  is  of  the  highest  importance 
to  the  best  advancement  of  hospital  and  dispensary  service  in  Cleveland 
that  the  Council  equip  itself  to  carry  its  increasing  responsibilities.  It  may 
be  noted  that  the  time  has  probably  arrived  when  a  substantial  share  of  the 
work  in  initiating  and  promoting  legislation,  in  which  the  Courcil  has 
achieved  so  much  success,  may  be  taken  over  by  the  Ohio  State  Hospital 
Association.    This  would  seem  a  logical  development. 

It  is  recommended  that  the  proposed  Central  Dispensary  Committee  be 
made  part  of  the  activities  of  the  Hospital  Council  as  soon  as  the  Council 
staff  is  able  to  carrv  the  additional  work. 


Hospitals  and  Dispensaries  983 


Hospital  Standards 

Membership  in  the  Hospital  Council  should  mean  to  other  hospitals  and 
to  the  public,  the  acceptability  of  the  hospital  according  to  standards  of  good 
organization  and  management.  The  chief  present  deficiency  of  the  Council 
is  due  to  the  fact  that  hospitals  have  been  accepted  as  members  whose  stand- 
ards have  been  too  far  below  those  of  the  average  maintained  by  the  Council, 
and  not  as  high,  in  one  or  two  institutions,  as  a  few  hospitals  not  members 
of  the  Council.  It  is  recognized,  however,  that  in  the  initial  formation  of  the 
Cleveland  Hospital  Council,  it  was  not  practicable  to  define  or  enforce 
standards  very  definitely.  The  time  has  now  come,  however,  when  definite 
minimum  standards  of  admission  should  be  publicly  known  as  well  as  pro- 
fessionally enforced.  The  Council,  through  its  committees,  officers,  and 
executive  staff,  should  be  the  democratic  professional  agent  of  the  hospitals 
and  dispensaries,  themselves,  for  their  own  improvement;  and  should  be  the 
advisor  of  the  Welfare  Federation  on  technical  questions  concerning  hos- 
pital and  dispensary  functions  and  standards. 

The  state1  and  city  governments,  through  the  regulative  acts  proposed, 
should  set  minimum  standards  and  an  institution  which  does  not  comply 
with  these  should  not  be  allowed  to  operate  at  all.  Between  the  minimum 
standards  and  the  desirable  hospital  standards  is  a  considerable  zone.  The 
Hospital  Council  should  not  take  in  this  twilight  zone,  but  should  always 
encourage  and  assist  institutions  which  are  within  its  shadow  to  move  as 
rapidly  as  possible  up  into  the  light. 

With  such  relations  between  the  state  and  city  governments,  the 
municipal  hospital,  the  Welfare  Federation,  and  the  Cleveland  Hospital 
Council  with  its  hospital  and  dispensary  experts,  it  is  believed  there  will 
exist  in  Cleveland  the  machinery  for  the  continued  advance  of  hospital  and 
dispensary  standards  of  administration.  If  such  progress  is  suitably  reported 
to  the  public  through  the  individual  hospitals  and  through  the  general  ac- 
tivities of  the  Council  and  Federation,  growing  interest  and  backing  for  hos- 
pital and  dispensary  work  should  be  annually  manifested,  expressing  itself 
in  more  intelligent  policies,  fuller  cooperation,  and  larger  funds  for  main- 
tenance and  for  permanent  improvement. 

But  organization  after  all  is  only  machinery.  It  is  the  ideals  and  spirit 
of  individuals  and  of  small  coherent  groups  working  together,  which  pro- 
vide the  motive  power  that  drives  institutions  and  communities  onward. 
The  schemes  of  organizers,  publicity  men,  and  financiers,  can  make  the  path 
easier  and  lessen  friction  during  the  forward  movement,  but  the  goal-posts, 
guides,  and  impelling  forces,  for  community  and  institution  alike,  depend 
upon  the  intangible  elements  of  the  individual  soul  and  the  civic  spLit. 
Cleveland  impresses  every  investigator  with  its  eager  readiness  for  cooper- 
ative activity.  With  such  a  community  spirit,  there  is  indeed  the  danger 
that  attainment  shall  be  measured  too  easily  in  terms  of  catch-words  and 
externals,  and  not  enough  by  the  more  abstract  but  more  fundamental  tests 


984 


Hospital  and  Health  Survey 


of  technic.  It  is  for  the  development  of  a  high  degree  of  Avell -founded  pro- 
fessional achievement  with  no  loss  of  its  present  splendid  tradition  of  com- 
munity endeavor  that  every  lover  of  Cleveland  must  hope. 


TABLE  I 


HOSPITALS  AND  DISPENSARIES  IN  CLEVELAND 


Institutions  Members  of  Cleveland  Hospital  Council 


Dis- 
pensary 
Hospital      Visits, 
Beds  1919 

Babies'      Dispensary     and 
Hospital — 2500   East 

Thirty-fifth  Street. 34*  14,977 

Cleveland  City  Hospital — 

Scranton  Road ._ 785 

Cleveland  Maternity  Hos- 
pital— 3735  Cedar  Ave.....     60       3,688 
Fairview  Park  Hospital — 

3305  Franklin  Avenue 85 

Glenville    Hospital — 701 

Parkwood  Drive... 74 

Grace   Hospital — 2307    W. 

Fourteenth  Street 35 

Huron  Road  Hospital — 748 

Huron  Road 84       5 ,  864 

Lakeside    Hospital — East 

Twelfth  and  Lakeside  Av.  289     59 ,  891 
Lakewood  Hospital — 14519 

Detroit  Avenue 53 

Lutheran     Hospital — 2605 

Franklin  Avenue 50 

Mount     Sinai     Hospital — 

1800  East  105th  Street...  225     19,324 

*In  summer  only. 


Dis- 
pensary 
Hospital       Visits, 
Beds  1919 

Provident    Hospital — 624 
East  103rd  Street 29 

Rainbow  Hospital — South 
Euclid,  Ohio... 85 

St.  Alexis  Hospital — 5163 
Broadway 250 

St.  Ann's  Maternity  Hos- 
pital— 3409  Woodland  Av.     55 

St.  Clair  Hospital— 4422 
St.  Clair  Avenue..... 43 

St.  John's  Hospital — 7911 
Detroit  Avenue _ 150 

St.  Luke's  Hospital — 6606 
Carnegie  Avenue 139     13,313 

St.  Vincent's  Charity  Hos- 
pital—  Central  and  East 
Twenty-second  Street 290     21,863 

Warrensville  Tuberculosis 
Sanitarium,  Warrensville, 
Ohio 270 

Woman's  Hospital — 1948 
East  101st  Street 37 


Hospitals  and  Dispensaries 


985 


Institutions  Not  Members  of  the  Cleveland  Hospital  Council 


Dis- 
pensary 
Hospital       Visits, 
Beds  1919 

fCarnegie  Avenue  Hospital 

— 8714  Carnegie  Avenue.. Unknown 

fClass  Mineral  Fumes  Treat- 
ments— 8101  Hough  Ave.. Unknown 

Cleveland  Emergency  Hos- 
pital—1780  East  Fifty- 
fifth  Street 22 

Cleveland   Home   Hospital 
— 5107  Prospect  Avenue  .     10 
fDelmont  Hospital  and  Sana- 
torium — 1770  Delmont 
Avenue Unknown 

Dorcas  Invalids'  Home — 
1380  Addison  Road 46 

East  Cleveland  Hospital — 
14420  Euclid  Avenue 31 

East  Fifty-fifth  Street  Hos- 
pital— 2415  East  Fifty- 
fifth  Street 60 

East  Seventy-ninth  Street 
Hospital — 1873  East  Sev- 
enty-ninth Street 24 

Eliza  Jennings  Home  for 
Incurables — 10603  Detroit 

Avenue 2  6 

fEuclid  Avenue  Hospital  and 
Sanatorium — 9810  Euclid 
Avenue Unknown 

Florence  Crittenden  Home 
—523  Eddy  Road 12 

Mrs.  Hitchcock's  Private 
Hospital — 5013  Prospect 
Avenue 1 5 


Hospital 
Beds 


Dis- 
pensary 
Visits, 
1919 


Holy  Cross  House: — 9014 
Cedar  Avenue 50 

Joanna  Private  Hospital — 
933  East  Seventy-eighth 
Street... 9 

Kate  Castle  Rhodes  Babies' 
Dispensary — 12611  Madi- 
son Avenue,  Lakewood 

fNeal  Institute  Company — 

3920  Euclid  Avenue.. ...Unknown 

fOhio  Sanitariums  Com- 
pany— 14822    Terrace 

Road - Unknown 

fOrthopedic  Institute — 1936 

East  Sixty-sixth  Street Unknown 

fReliable  Invalid  Home — 
2222  East  Eighty-ninth 
Street. Unknown 

Rest-Cure  Hospital  and 
Sanatorium — 2453  East 
Fifty-fifth  Street... 16    (in  use) 

St.  Mark's  Hospital— 629 
Eddy  Road 45 

Salvation  Army  Rescue 
Home — 5905  Kinsman 
Road --:-     54 

U.  S.  Marine  Hospital — 
1041  Lakeside  Avenue 86       4,493 

Windsor  Sanatorium — 4415 
Windsor  Avenue 38 

Wright's  Hospital— 18902 
Nottingham  Road 10 

Y.  W.  C.  A.  Retreat— 4916 

St.  Clair  Avenue Temporarily 

Closed 


■{■Institutions  not  reported  as  registered  with  the  State  Department  of  Health  up  to  June,  1920. 


986 


Hospital  and  Health  Survey 


-502  Central  Ave. 
3 — 2810    Seymour 


Public  Health 

Health  Center  No.  1 — 1510  East  Forty 

ninth  Street. 
Health  Center  No.  2 
Health    Center    No. 

Avenue. 
Health  Center  No.  4 — 5825  Cable  Ave. 
Health  Center  'No.   5 — 9206   Woodland 

Avenue. 
Health   Center   No.    6 — 10126   St.   Clair 

Avenue. 
Health  Center  No  7 — 6100  Pear  Avenue. 
University  Health  Center — 2739  Orange 

Avenue. 

Prophylactic  Baby  Stations — 

5706  Clark  Avenue. 
7654  Broadway. 
12510  Mayfield  Road. 


Dispensaries 

4247  Pearl  Road. 
833  East  152d  Street. 
3008  Bridge  Avenue. 
2511  East  Thirty-fifth  Street. 
Prenatal  Clinics— 
Maternity    Hospital    Dispensary — 2509 
East  Thirty-fifth  Street. 

(Sub-stations) 
2749  Woodhill  Road. 
Alta  House,  12510  Mayfield  Road. 
2317  Lorain  Avenue. 
Goodrich  House,    1420    East    Thirty- 
first  Street. 
East  Forty-ninth  and  Fleet  Street. 
Mount  Sinai  Hospital — 1800  East  105th 

Street 
St.     Luke's     Hospital — 6606     Carnegie 
Avenue. 


TABLE  II 
PERCENTAGE  OF  OCCUPANCY 


OF  HOSPITAL  BEDS 


HOSPITAL 


City : 

Fairview  Park. 

Glenville. 

Grace._ _ 

Huron  Road 

Lakeside 

Lakewood 

Lutheran..... 

Maternity 

Mount  Sinai... 

Provident. 

St.  Alexis 

St.  Ann's... 

St.  Clair 

St.  John's 

St.  Luke's. 

St.  Vincent's.... 
Woman's..— 


Beds* 
1919 

Per  Cent. 

Occupied 

1919 

Per  Cent. 

Occupied 

1918 

Per  Cent. 

Occupied 

Census  Days 

Averaged 

785H 

60.3 

82.2 

70.0 

85 

60.4 

62.3 

67.6 

74 

66.3 

72.3 

69.0 

35 

66.8 

52.7 

94.3 

84 

75.0 

68.2 

86.9 

289 

90.8 

82.6 

72.9 

53 

45.9 

40.7 

68.0 

50 

80.9 

70.5 

93.0 

60* 

79.9 

70.3 

71.7 

225f 

72.4 

81.7 

84.2 

29 

40.5 

49.4 

65. 5  J 

250 

78.1 

78.0 

97.8 

55** 

Unknown 

75.0 

93.7 

43 

40.2 

58.6 

33.7 

150 

Unknown 

79.0 

90.1 

139 

75.8 

71.6 

95.3 

290 

66.9 

58.1 

73.0 

37 

76.0 

Unknown  ff  Unknown 

*For  maternity  cases,  adult  beds  only  were  included,  except  for  Maternity  Hospital  for  1919,  which 
was  figured  on  a  basis  of  60  mothers  and  33  cribs,  as  the  bed  days  reported  included  both  mothers  and 
babies. 

tMt.  Sinai  for  1918  was  figured  on  a  155-bed  basis;  for  1919  on  a  basis  of  155  beds  for  February 
and  March,  and  225  for  the  remaining  ten  months. 

tProvident  furnished  data  for  the  first  Survey  Census  day  only. 

**St.  Ann's  figures  for  1919  were  not  furnished. 

ttNo  definite  information  was  available  regarding  beds  at  Woman's  for  1918. 

tJCity  was  figured  on  basis  of  650  beds  until  December,  1918,  and  785  beds  thereafter.  Since  the 
field  work  of  the  Survey  was  completed,  figures  were  furnished  by  the  City  Hospital  Administration, 
based  on  725  beds  which  were  available  for  1919,  instead  of  785.  This  gives  the  percentage  occupied  for 
the  year  in  the  hospital  as  a  whole,  as  66.5  per  cent.  Further  details  of  importance  regarding  City  Hos- 
pital will  be  found  in  the  foot-note,  page  834. 


Hospitals  and  Dispensaries 


987 


TABLE  III 
HOSPITAL  BEDS  ACCORDING  TO  HEALTH  DISTRICTS* 


District     Type  of  District 
I Factory 


Popula- 
tion 
of 
District 

82,185 


Beds  to       Hospital  Cases 
1000  of     to  1000  of  Pop- 
Population        ulation  of 
of  District         District 
(Census  I)        (Census  I) 


Total 
Hospitals  Hospital 

in  Beds  in 

District  District 

Lakeside 429  . 

St.  Clair 
Cleveland 

Emergency 

Huron  Road 84 

City 820 

Grace 

St.  Alexis.... 293 

East  79th 
Florence    Critten- 
den 
Joanna  Private 

St.  Luke's 280 

Holy  Cross 
Salvation  Army 
Rescue  Home 
Woman's 

Glenville 373 

Mount  Sinai 

Provident 
St.  Mark's 

Fairview  Park 285 

Lutheran 
St.  John's 

Maternity 490 

St.  Ann's 
St.  Vincent's 
East  55th  Street 
Cleveland  Home 
Mrs.    Hitchcock's 
Private 

Lakewood ..  53 

Rainbow  85 

Warrensville  Tu- 
berculosis Sana- 
torium   270 

Wright's.. 10 

East  Cleveland  ....  31 

*It  will  be  observed  that  the  population  figures  are  those  which  were  furnished  the  Survey  from  loca 
estimates,  and  are  higher  than  those  given  in  the  1920  census.  For  the  sake  of  uniformity,  these  esti- 
mated population  figures  have  been  used  throughout  this  table  since  its  purpose  is  primarily  the  com- 
parison of  different  districts,  and  census  figures  for  anything  except  the  city  as  a  whole  were  not  available 
at  the  time  of  writing  this  report. 


II  _ .Factory,  Congested     42 ,  159 

III_ Near  Congested......  130 ,  775 

IV Factory,  Congested  164,094 


V Part  Congested  ......   136,294 

Part  Residential 


VI ...Industrial 176,836 

Residential 

Congested 

VII Semi-congested 90 ,  766 

Residential 

VIII Congested 72 ,  168 


Outside 
City 

Limits .... 


5.2 


2.0 
6.3 


1.8 


2.1 


2.1 


3.1 


6.8 


2.7 


3.5 
1.2 


1.2 


1.9 


2.1 


2.1 


4.1 


988 


Hospital  and  Health  Survey 


TABLE  IV 

PERCENTAGE  OF  HOSPITAL  PATIENTS  COMING  FROM  HEALTH 
DISTRICT  IN  WHICH  HOSPITAL  IS  LOCATED 
(First  Survey  Census  Day) 


Cleveland  City...... 4.6 

Cleveland  Maternity .....13  .  7 

Fairview  Park ...36 .  7 

Glenville 46.7 

Grace .3  2  . 3 

Huron  Road 6 . 6 

Lakeside* 

Lakewoodf.. 

Lutheran _ 44.2 


Mount  Sinai 31 . 2 

Provident 78.9 

St.  Alexis 35 . 9 

St.  Ann's 59 . 8 

St  Clair... .28 . 6 

St  John'sJ 

St.  Luke's.. 15 . 6 

St.  Vincent's 0.0 

Woman's  .26.0 


*Address  not  furnished  for  52  per  cent,  of  patients. 
fHospital  outside  city  limits  of  Cleveland. 
JAddress  not  furnished  for  59  per  cent,  of  patients. 


TABLE  V 

PERCENTAGE    OF    CASES,    CLASSIFIED   ACCORDING   TO    COMPENSATION 

FOR  CARE,  ADMITTED  THROUGH  VARIOUS  SOURCES  TO 

THREE  LARGE  GENERAL  HOSPITALS 

Patients  Admitted  to  Hospital  No.  I.,  Classified  According  to  Compensation  for 

Care,  and  Source  of  Reference 


Percentage 

Percentage 

Percentage 

Percentage 

of  total 

referred  by 

referred  by 

referred  by 

Percentage 

admissions 

staff 

non-staff 

by  charitable 

not 

physicians 

physicians 

agencies 

classified 

Patients  paying  full  cost  of 

care 41.9  53.0  43 .2  2.2  1.6     100^ 

Patients    paying    part    of 

cost  of  care..... 20 . 8 

Patients     paying     nothing 

for  care 30 . 1 

Patients  not  classified 7 .  2 

100% 

Percentage  of  total  admis- 
sions   37.9  44.3  15.6         2.1      100% 

(excepting  patients  not 
classified  as  to  compen- 
sation) 


9.3 

40.5 

20.2 

0.0     100^v 

4.8 

45.8 

35.7 

3.7    iooc;, 

0.4 

34.4 

65.2 

oo    iooc; 

Hospitals  and  Dispensaries 


989 


TABLE  V— Continued 

PERCENTAGE   OF   CASES,    CLASSIFIED   ACCORDING   TO    COMPENSATION, 

FOR  CARE,  ADMITTED  THROUGH  VARIOUS  SOURCES  TO 

THREE  LARGE  GENERAL  HOSPITALS 

Patients  Admitted  to  Hospital  No.  II,  Classified  According  to  Compensation  for 

Care,  and  Source  of  Reference 


Patients  paying  full  cost 
of  care 

Patients  paying  part  of 
cost  of  care. 

Patients  paying  nothing 
for  care. 

Patients  not  classified 

Percentage  of  total  admis- 
sions  

(excepting  patients  not 
classified  as  to  compen- 
sation) 


Percentage 
of  total 

admissions 

Percentage 
referred 
by  staff 

physicians 

Percentage 

referred  by 

non-staff 

physicians 

Percentage 

referred  by 

charitable 

agencies 

Percentage 

not 

classified 

27.9 

67.5 

32.5 

0.0 

0.0 

100% 

40.9 

68.0 

30.9" 

1.1 

0.0 

100% 

15.5 

47.7 

29.2 

20.0 

3.1 

100% 

15.7 

77.3 

22.7 

0.0 

0.0 

100% 

100% 

59.0 

35.5 

4.2 

1.3 

100% 

Patients  Admitted  to  Hospital  No.  Ill,  Classified  According  to  Compensation  for 

Care,  and  Source  of  Reference 


Patients  paying  full  cost 
of  care _ _ 

Patients  paying  part  of 
cost  of  care 

Patients  paying  nothing 
for  care 

Patients  not  classified 

Percentage  of  total  admis- 
sions  

(excepting  patients  not 
classified  as  to  compen- 
sation) 


Percentage 

of  total 
admissions 

Percentage 
referred 
by  staff 

physicians 

Percentage 

referred  by 

non-staff 

physicians 

Percentage 

referred  by 

charitable 

agencies 

Percentage 

not 

classified 

30.5 

56.4 

43.6 

0.0 

0.0 

100% 

49.3 

50.0 

50.0 

0.0 

0.0 

100% 

20.2 

73.5 

26.5 

0.0 

0.0 

100% 

0.0 

0.0 

0.0 

0.0 

0.0 

0.0 

100% 


68.9 


31.1 


0.0 


0.0 


990  Hospital  and  Health  Survey 

TABLE  VI 
FINANCES  OF  HOSPITALS  IN  CLEVELAND  HOSPITAL  COUNCIL,  1919 

Municipal 

Total  Expense  Total  Earnings        Percentage    Ex- 

for  Hospital  from  Operation    penses  are  of  Total 

Earnings 

Cleveland  City  Hospital $428 ,  636 .  77 

Warrensville  Tuberculosis  Sanatorium 197 ,  020 .  15 


7,000 

10.4% 

58,802 

65.0 

65,000 

76.5 

Total  Municipal... $625 ,  656 .  92 

Non-Municipal 

*Babies'  Dispensary. _  67 ,305 

♦Cleveland  Maternity 90,435 

*Fairview  Park 85 ,  000 

tGlenville... 

*Grace 33,000  33,000  100.0 

*HuronRoad 117,600  83,800  71.3 

*Lakeside 480,000  264,000  55.0 

*Lakewood..._ ■ , 58,000  52,000  89.7 

JLutheran _         

fMount  Sinai 332  ,  000  200 ,  000  60 . 4 

*Provident 14,000  13,000  92.9 

♦Rainbow 63,445  12,910  20.4 

*St.  Alexis _ 108,800  70,000  64.3 

*St.  Ann's , 107,125  84,888  79.2 

*St.  Clair.... 36,975  28,390  76.7 

*St.  John's 169,342  120,200  70.9 

*St.  Luke's... 207,120  176,820  85.4 

*St.  Vincent's 249,350  204,800  82.1 

♦Woman's 50,083  39,600  79.2 


Total  Non-Municipal $2 ,  269 ,  580 .  00 

Grand  Total $2 ,  895 ,  236 .92         $1 ,  514 ,  210 

Summary  for  Non-Municipal  Hospitals  (so  far  as  calculable) 

Subtotal,  Expense  for  Hospitals $1 ,  927 ,  993  .  00 

Subtotal,  Earnings  from  Operation. 1,296,214.00 

Bed  Days  Care,   1919 _ 439,700 

Average  Cost  per  Day  of  Care $4 .  39 

Average  Earnings  per  Day  of  Care $2 .  95 

Percentage  of  Average  Cost  per  Day  of  Care  Earned  from 

Operation 67 . 2 

*Budget  for  these  institutions  covers  the  year  from  October  1,  1919,  to  September  30,  1920. 

tBudget  for  this  institution  covers  the  year  from  January  1,  1920,  to  December  31,  1920. 

tin  order  to  estimate  the  average  cost  and  average  earnings  per  day  of  care  for  non-municipal  hos- 
pitals, it  is  necessary  to  omit  the  following  hospitals  from  the  calculation:  Glenville  and  Lutheran,  as  at 
the  time  of  preparing  the  table,  the  total  cost  and  total  earnings  of  these  institutions  for  1919  could  not  be 
ascertained;  and  also  Rainbow,  St.  Ann's,  and  St.  John's,  as  at  the  time  of  preparing  the  table,  the  num- 
ber of  bed  days  care  for  the  year  1919  could  not  be  ascertained.  The  figures  in  the  summary  therefore  do 
not  make  a  total  as  large  as  in  the  non-municipal  group  in  the  table. 


Hospitals  and  Dispensaries  991 

TABLE  VII 
SUMMARY  OF  CONVALESCENT  CASES 

Charity                  City                Lakeside  Mt.  Sinai 

Cases  with  Home  Environment                   Cases.  Per  ct.  Cases.  Per  ct.  Cases.  Per  ct.  Cases  Per  ct. 

Favorable  and  Adequate 15       30.0       5         7.0       4         7.0  1  4.5 

Favorable  with  minor  adjustments 21       42.0     19       26.8     21       36.8  10  45.5 

Unfavorable  but  remediable 6       12.0     21       29.6     14       24.6  7  31.8 

Unfavorable  and  not  remediable 6       12.0     20       28.2     16       28.1  2  9.1 

Acutely  needing  further  hospital  care.—       2         4.0       6         8.4       2         3.5  2  9.1 


Cases  with  Home  Environment 

Favorable  and  Adequate 

Favorable  with  minor  adjustments.. 

Unfavorable  but  remediable 

Unfavorable  and  not  remediable 

Acutely  needing  further  hospital  care 


50 

100.0 

71 

100.0 

57     100.0 
Total  cases 

25 
71 
48 

44 
12 

22     100.0 

Total  Per  ct.  ' 
12.5 

35.5 

24.0 

22.0 

6.0 

200  100.0 


TABLE  VIII 

PATIENTS  REMAINING  IN  HOSPITAL  OVER  TWO  MONTHS 

Number  of  patients  Percentage  of  patients 

Number  of  patients  remaining  over  two  remaining  over  two 

HOSPITAL                               on  Survey  census  months  on  census  months  on  census 

days,  averaged  days,  averaged  days,  averaged 

Cleveland  City.... 549 .5  162  . 5  29  . 6% 

Cleveland  Maternity 43 . 0  0.0  0.0 

FairviewPark 57.5  2.5  4.3 

Glenville 51.0  1.0  2.0 

Grace 33.0  2.0  0.6 

Huron  Road 73.0  6.5  8.9 

Lakeside ,. 215.5  26.0  12.1 

Lakewood 36.0  3.0  8.3 

Lutheran 46.5  0.5  0.1 

Mt.  Sinai 160.0  8.0  5.0 

Provident 19.0*  0.0  0.0 

St.  Alexis 244.5  22.5  9.2 

St.  Ann's 51.5  0.5  0.9 

St.  Clair 14.5  1.0  6.9 

St.  John's 137.0  9.5  6.9 

St.  Luke's 132.5  4.5  3.4 

St.  Vincent's _ 210.0  15.0  7.1 

Woman's 43.0  0.0  0.0 

Totals... 2,117.0  265.0  7.9 

""Information  was  received  from  Provident  Hospital  for'the  first  Survey  census  day  only. 


Hospital  and  Health  Survey 


PROPOSED  FORM  FOR  SHOWING 
HOSPITAL  AND  DISPENSARY  SERVICE  OF  CLEVELAND 
As  Rendered  by  the  Members  of  the  Cleveland  Hospital  Council  During  19 


Hospital— 

Number  of  Beds 
Total  Hospital  Days  Care 
Percentage  of  Possible  Days  Care 
Classes  of  Patients 

Pay  Patients 
Number 

Part-pay  Patients 

Number 

Days  Care 
Free  Patients 

Number 

Days  Care 
Percentages  of  Days  Care 

Pay 

Part -pay 

Free 
Equivalent  Free  Days 
Sex  and  Age  of  Patients 

Women 

Children  under  15 
Average  Days  Stay  per  Patient 
Total  Number  of  Patients 
Income 

From  Operation 

From  Endowment 

From  Community  Fund 

From  Other  Sources 

Percentage  from  Operation 

Percentage  from  Community  Fund 
Expenditures 

Total  for  Hospital 

Average  per  Days  Care 

Average  per  Day  for  Food  Only 

Dispensary 
Total  Visits 
New  Patients 

Women 

Children  under  15 

Total 
Average  Visits  per  Day 
Average  Visits  per  Patient 

From  Operation 
From  Endowment 
From  Community  Fund 
From  Other  Sources 
Percentage  from  Operation 
Percentage  from  Community  Fund 

Total 

Average  per  Visit 

Ambulance  Calls  Made 
Total 

Average  per  Day 
Total  Cost 

Average  Cost  per  Call 
Personnel 

Total  number  on  December  31st,  of 

Visiting  Medical  Staff 

Resident  Medical  Staff 

Employes 


N.  B. — The  above  form  for  a  table  is  deiigr 
which  should  be  tabulated,  for  each  hospital, 

name  of  the  institution.  The  right-hand  column  will  show  the  total  for  all  the  members 
of  the  Hospital  Council  taken  together.  An  additional  column  might  be  added,  giving 
for  comparison  the  totals  of  the  preceding  year.  It  should  be  understood  that  the  above 
condensed  form,  printed  here  as  illustration,  shows  only  two  columns  for  hospitals,  whereas 
the  form  actually  to  be  used  would  include  a  column  for  each  member  of  the  Council. 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VIII.     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

X.     Hospitals  and  Dispensaries. 

XL     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 


The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 


THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Premier  Press 

Cleveland,  O. 


Method  of  Survey 

Bibliography  of  Surveys 

Index 


Part  Eleven 


Cleveland    Hospital     and 
Health    Survey 


Copyright,  1920 
by 

The  Cleveland  Hospital  Council 

Cleveland,  Ohio 


Published  by 

The  Cleveland  Hospital  Council 

308  Anisfield  Bldg 
Cleveland    -   Ohio 


Preface 

The  Hospital  and  Health  Survey  of  Cleveland  was  made  at  the  request 
of  the  Cleveland  Hospital  Council. 

The  Survey  Committee  appointed  to  be  directly  responsible  lor  the 
work  and  through  whose  hands  this  report  has  been  received  for  publica- 
tion consisted  of  the  following: 

Malcolm  L.  McBride,  Chairman; 

Mrs.  Alfred  A.  Brewster, 

Thomas  Coughlin, 

Richard  F.  Grant, 

Samuel  H.  Halle, 

Otto  Miller, 

Dr.  H.  L.  Rockwood, 

Howell  Wright,  Secretary 

The  staff  responsible  for  the  work  were: 

Haven  Emerson,  M.  D.,  Director, 

and  the  following  collaborators : 
Gertrude  E.  Sturges,  M.  D.,  Assistant  Director; 
Michael  M.  Davis,  Jr.,  Ph.  D.,  Director  of  the  Hospital  and 

Dispensary  Survey; 

Josephine  Goldmark,  B.  A.,  Director  of  the  \Nursing  Survey; 

Wade  Wright,  M.  D.,  Director\of  the  Industrial  Hygiene  Survey; 

Donald  B.  Armstrong,  M.  D.,  Director  of  Tuberculosis  Survey; 

S.  Josephine  Baker,  M.  D.,  D.  P.  H.,  Director  of  the  Infant 
and  Maternity  Survey; 

T.  W.  Salmon,  M.  D.,  Director  of  the  Mental  Hygiene  Survey; 

W.  F.  Snow,  M.  D.,  Director  of  the  Venereal  Disease  Survey; 

Louis  I.  Dublin,  Ph.  D.,  Director  of  the  Vital  Statistics  Survey. 

The  expenses  of  the  Survey  and  of  the  publication  of  the  report  have 
been  met  by  appropriations  received  from  the  Community  Chest,  through 
the  WTelfare  Federation,  of  which  the  Hospital  Council  is  a  member. 

The  report  as  a  whole,  or  by  sections,  can  be  obtained  from  the  Cleveland . 
Hospital  Council.     A  list  of  the  parts  will  be  found  in  the  back  of  this  volume, 
together  with  prices. 


TABLE  OF  CONTENTS 

I.     Method  of  Making  a  Community  Diagnosis 

Page 
Introduction — Why  a  Survey  is  Necessary 1003 

Preliminary  Steps: 

Realization  of  the  Need 1004 

Cost  to  be  Considered.... 1004 

Committee 1004 

Choosing  the  Group  of  Diagnosticians 1005 

Scope : 

History  of  Survey 1005 

Factors  Influencing  Scope 1007 

Aims*and  Methods : 

Interpretation  of  Results :... 1009 

Education  of  the  Patient 1009 

Community  History  Taking 1010 

Quantitative  Estimate  of  Needs 1010 

Law  and  Law  Enforcement 1010 

Coordination  and  Functional  Control 1011 

The  Associated  Health  Professions  and  Their  Training.... 1012 

Quantitative  Determinations  of  Functions 1012 

Quality  of  Function 1013 

Resources  for  Prevention 1015 

Checking  up  the  facts  for  Diagnosis.. 1015 

Conclusion : 

Treatment  and  Follow-up 1016 

Appendix : 

Form  Letters  and  Questionnaires 1018 

II.    Bibliography  of  Surveys 

Health  Administration  Surveys..... 1038 

Mental  Hygiene  Surveys... 1044 

Infant  Mortality  Surveys.... 1049 

Social  Surveys 1052 

Industrial  Hygiene  Surveys... 1054 

Tuberculosis  Surveys 1057 

Sickness  Surveys _ 1059 

Unclassified 1060 

III.     Index 1061 


Method  of  Making  a  Community  Diagnosis 

By  Haven  Emerson,  M.  D.,  and  Gertrude  E.  Sturges,  M.  D. 
INTRODUCTION:    WHY  A  SURVEY  IS  NECESSARY 

WHAT  is  a  survey,  and  why  does  Cleveland  or  any  other  city  need  the 
luxury  of  a  diagnosis?  A  diagnosis  implies  the  presence  of  ill  health. 
Is  Cleveland  sick?  Even  as  the  careful  and  thrifty  owner  has  his  car 
overhauled  to  prevent  delay  upon  the  road  or  accident  under  strain,  and  as 
the  young  husband  looks  far  into  the  future  and  insures  his  life,  so  a  city 
may  well  indulge  in  community  insurance  by  a  periodical  searching  for  weak 
joints  in  its  organization,  loose  bolts,  missing  parts,  proof  of  wear  and  tear, 
need  of  replacement  and  reinforcement  of  its  structure. 

While  all  the  world  is  clamoring  for  production,  it  is  worthy  of  great  praise 
that  a  community  should  determine  that,  in  one  place  at  least,  the  producer 
shall  rank  ahead  of  the  produce  in  their  thoughts  and  plans. 

Property  will  always  have  its  protectors  and  promoters.  It  is  persons 
who  are  chiefly  neglected,  and  for  these  the  community  health  diagnosis 
takes  thought.  How  may  their  sickness  be  prevented,  their  lives  made 
longer  and  happier  and  if  sickness  overtakes  them,  how  may  skill  and  gentle- 
ness be  put  quickly  at  their  service? 

To  survey  is  to  view  with  attention  as  from  a  height — to  prospect,  to 
examine,  and  in  so  doing  to  make  a  review  and  retrospect,  to  use  history 
and  present  experience  as  a  basis  for  programs  for  the  future  to  insure  prog- 
ress. 

•  The  community  physician  should  detect  the  presence  of  all  factors  affect- 
ing health  and  formulate  all  practical  and  economical  measures  to  decrease 
disease  and  increase  comfort. 

The  public,  as  investors  in  the  Community  Fund,  are  stockholders  in  the 
various  institutions  supported  by  this  fund,  and  as  stockholders,  are  entitled 
to  a  statement  of  results — as  to  the  per  capita  costs  as  well  as  the  quality 
and  quantity  of  the  output.  The  contributing  public  and. more  particularly 
the  boards  of  trustees  of  the  various  institutions,  have  a  definite  respon- 
sibility also  in  seeing  that  the  funds  which  are  provided  are  made  to  serve 
the  best  interests  of  the  community.  They  should  make  sure  that  the  high- 
est degree  of  professional  service  is  rendered  through  the  institutions  for 
which  they  are  responsible  and  that  the  same  principles  of  organization 
and  efficiency  are  carried  out  as  in  up-to-date  business  enterprises.  To  this 
end  it  is  essential  that  both  the  character  of  professional  service  and  the  type 
of  business  administration  receive  the  thorough  investigation  of  experts  from 
time  to  time. 

It  is  also  pertinent  for  the  investors  to  know  whether  there  is  any  over- 
lapping of  effort  or  duplication  of  function  by  existing  institutions  that  could 


1004         •  Hospital  and  Health  Survey 

be  obviated  by  more  clearly  defined  policies  or  by  a  division  of  the  territory 
to  be  covered  by  each  institution.  What  preventive  or  curative  needs  are 
not  being  provided  for  adequately:  i  e.,  measured  by  the  estimated  service 
required  for  prenatal  care,  for  dispensary  service,  for  hospitalization,  etc., 
what  failures  to  meet  the  need  are  apparent?  What  services  are  not  being 
rendered  at  all?  In  an  extensive  view  of  all  the  city's  activities  for  preven- 
tion and  treatment  of  disease,  for  education  of  physicians  and  members  of 
the  allied  professions,  what  distinct  gaps  exist  in  the  service?  Is  there  an 
understanding  of  the  precise  problems  to  be  solved  and  of  the  ways  and 
means  by  which  they  may  be  solved?  Are  all  modern  information  and  experi- 
ence in  the  prevention  as  well  as  the  treatment  of  sickness,  sufficiently  under- 
stood by  each  agency  serving  the  public?  Until  every  doctor,  nurse  and 
health  visitor  working  among  the  sick  is  aware  of  the  resources  and  applica- 
tion of  preventive  medicine  to  health  protection,  no  possible  increase  in 
hospitalization  of  the  sick  will  meet  the  needs  of  the  city.  Each  case  of  sick- 
ness presents  a  problem  of  prevention  as  well  as  of  relief,  of  education  as 
well  as  of  treatment,  of  the  family  and  the  home  as  well  as  of  the  individual 
patient.  And,  finally,  is  there  adequate  provision  made  for  coordinating 
the  activities  of  the  private  health  agencies  to  the  end  that  they  may  provide 
the  maximum  service  with  the  minimum  of  effort  and  of  overhead  expense? 

PRELIMINARY  STEPS 

With  some  of  the  problems  in  mind  to  be  answered  by  the  community 
diagnostician,  what  are  the  preliminary  steps  to  be  taken? 

Realization  of  the  Need 

First  the  patient  must  realize  that  he  needs  the  services  of  a  physician 
and  must  be  prepared  to  render  him  every  assistance.  Without  not  only  the 
patient's  consent  but  his  eager  and  willing  assistance,  no  physician  can  get 
all  the  facts  needed  before  prescribing.  A  community  differs  in  this  respect 
chiefly  in  quantity,  not  in  elements  for  diagnosis,  from  the  individual  patient. 

Cost  to  be  Considered 

Sufficient  financial  support  must  be  assured  to  "pay  the  doctor's  bill." 
In  Cleveland  adequate  provision  for  financing  the  Survey  was  made  from  the 
Community  Fund,  at  the  request  of  the  Cleveland  Hospital  Council  through 
the  medium  of  the  Welfare  Federation.  A  sum  of  $53,000  was  appropriated 
for  this  purpose  of  which  $52,668.98  was  spent.*  It  is  interesting  to  note 
in  this  connection  that  service,  conservatively  estimated  to  be  worth  over 
$10,000,  has  been  given  to  the  Cleveland  Survey  by  cooperating  national 
and  local  organizations. 

The  Committee  in  Charge 

The  organization  or  committee  under  whose  auspices  the  community 
study  is  to  be  conducted  is  another  matter  for  preliminary  consideration.     In 

•This  amount  was  estimated  at  the  time  of  going  to  press. 


Method  1005 

order  that  every  institution  may  feel  itself  an  integral  part  of  the  group  con- 
ducting the  Survey,  the  committee  should  be  as  representative  as  possible 
and,  that  good  feeling  may  be  assured,  men  and  women  known  to  be  broad 
in  their  judgments  should  be  chosen. 

In  Cleveland  the  Survey  has  been  conducted  under  the  direct  supervision 
of  a  special  committee  of  the  Hospital  Council,  consisting  of  public-spirited 
business  men,  a  woman  representing  the  nursing  interests,  the  Commissioner 
of  Health  and  the  secretary  of  the  Hospital  Council.  The  Hospital  Coun- 
cil itself  is  a  cooperative  organization  consisting  of  representatives  of  the 
boards  of  trustees  and  superintendents  of  the  public  and  private  hospitals 
in  the  city.  The  committee  must  be  able,  as  this  one  was,  to  open  all  the 
doors  of  the  city.  By  the  position,  character,  professional,  business  and 
social  standing  of  its  members,  it  must  be  able  to  give  access  for  the  sur- 
veyors to  all  important  public  and  private  groups  who  can  give  information 
or  spread  it.  The  editorial  offices  of  the  daily  papers,  the  offices  of  city  gov- 
ernment, the  clubs,  churches,  professional,  business  and  social  groups  must 
be  readily  accessible  and  hospitable  to  the  inquiries  that  lead  into  the  in- 
timacies of  community  history,  and  willing  to  take  trouble  to  see  that  needs 
and  recommendations  are  frankly  discussed  and  acknowledged. 

The  Group  of  Diagnosticians 

Choosing  the  doctor  and  his  colleagues  is  the  first  problem  with  which 
the  committee  is  confronted.  The  group  of  diagnosticians  should  possess 
not  only  knowledge  of  the  field  to  be  studied,  but  wide  experience  with 
conditions  in  other  cities,  in  order  that  they  may  have  a  background  for 
guaging  local  problems.  Impartiality  will  generally  be  better  assured  by 
selecting  the  entire  Survey  staff  from  outside  the  city. 

The  Cleveland  Hospital  and  Health  Survey  has  been  particularly  fortu- 
nate in  securing  the  cooperation  of  many  national  agencies  which,  because  of 
the  wealth  of  their  experience,  are  in  an  ideal  position  to  survey  any  locality. 

SCOPE 

The  scope  of  a  survey  may  be  either  intensive  or  extensive;  either  an 
analysis  of  one  phase  or  agency  of  health  service  or  a  general  health  survey; 
i.  e.,  the  examination  of  a  single  part  of  the  body,  one  of  the  special  senses 
or  a  general  medical  examination. 

Historical 

It  is  interesting  in  this  connection  to  study  briefly  the  range  of  previous 
surveys.  A  study  of  available  literature  at  the  Russell  Sage  and  medical 
libraries  brought  out  the  fact  that  surveys  of  health  administration  and  allied 
subjects  are  numerous.  (See  bibliography  of  surveys).  These  are  the  case 
histories  of  community  patients.  Eighty  such  surveys  have  been  made  in 
thirty  different  states  (several  covering  more  than  one  state)   and  also  in 


1006  Hospital  and  Health  Survey 

two  foreign  countries.  New  York,  Illinois,  Ohio,  Pennsylvania  and  Min- 
nesota ranked  in  that  order  in  the  number  of  public  health  studies  that  had 
been  made  upon  various  of  their  communities.  These  investigations  have 
been  conducted  chiefly  by  the  United  States  Public  Health  Service,  by  state 
or  local  health  departments,  by  the  New  York  or  local  bureaus  of  municipal 
research,  by  the  Russell  Sage  Foundation  and  by  local  Chambers  of  Com- 
merce. 

■> 

Mental  hygiene  was  the  subject  next  in  order  of  attractiveness  to  the 
surveying  mind.  Results  of  sixty-three  studies  of  this  subject  were  found. 
Many  of  these  have  been  made  by  the  National  Committee  for  Mental 
Hygiene  and  several  by  state  or  local  charitable  organizations. 

Search  brought  to  light  thirty-eight  infant  mortality  and  child  health 
studies.  The  largest  number  of  these  had  been  prepared  by  the  United 
States  Children's  Bureau,  although  the  Russell  Sage  Foundation  and  the 
National  Child  Labor  Committee  had  each  conducted  several  studies  of  this 
type. 

Thirty-four  social  surveys  were  found,  made  by  a  wide  variety  of  groups. 
This  number  includes  only  the  most  important  contributions  along  this  line. 
The  list  could  be  greatly  increased,  no  doubt,  by  the  addition  of  all  the 
local  social  studies  that  have  been  made,  reports  of  which  were  not  sought 
for  particularly  in  this  review  of  the  litarature. 

There  were  records  of  twenty-nine  industrial  hygiene  investigations,  half 
of  which  were  made  in  New  York  City,  six  by  the  New  York  City  Depart- 
ment of  Health.  Many  studies  of  industrial  hazards  have  also  been  made 
by  the  United  States  Public  Health  Service  and  by  the  United  States  De- 
partment of  Labor. 

There  were  records  of  twenty-five  tuberculosis  surveys,  many  of  them 
made  under  the  auspices  of  the  national  or  local  anti-tuberculosis  societies. 
The  effect  of  industry  on  the  incidence  of  tuberculosis  is  the  subject  of  many 
of  these  investigations.  The  influence  of  housing  and  economic  conditions, 
nationality  and  race  were  some  other  main  points  covered  in  these  studies, 

The  amount  and  character  of  sickness  in  various  communities  have  been 
the  object  of  twelve  investigations — most  of  them  conducted  by  the  Metro- 
politan Life  Insurance  Company. 

The  most  comprehensive  surveys  that  have  been  made  are :  the  Pittsburgh 
Survey,  the  record  of  which  is  published  in  six  volumes,  embracing  the  fol- 
lowing among  its  major  topics — civic  improvements,  industrial  hygiene, 
housing,  schools,  playgrounds,  libraries,  social  agencies — and  The  Spring- 
field, Illinois,  Survey  which  includes  studies  of  schools,  mental  hygiene,  rec- 
reation, housing,  charities,  industrial  conditions,  city  and  county  ad- 
ministration, public  health  and  the  correctional  system. 

One  hundred  and  eighty-four  authors  were  responsible  for  the  two  hun- 
dred and  eighty-one  investigations  above  summarized.     There  are  many 


Method  1007 

authors  of  several  surveys — L.  K.  Frankel  and  L.  I.  Dublin,  studies  of  sick- 
ness incidence;  C.-E.  A.  Winslow,  Carrol  Fox  and  Franz  Schneider,  Jr., 
health  administration  and  sanitation;  Thomas  W.  Salmon,  T.  H.  Haines, 
E.  O.  Lumberg,  W.  L.  Treadway  and  S.  D.  Wilgus,  studies  in  the  field  of 
mental  hygiene;  J.  W.  Schereschewsky  and  L.  I.  Hanes,  surveys  of  industrial 
hygiene;  Shelby  M.  Harrison,  social  surveys;  W.  H.  Slingerland,  studies  in 
prevention  of  infant  mortality. 

The  report  of  a  study  made  by  the  Northeastern  Hospital  Association,  of 
the  hospital  facilities  in  an  area  of  about  4,000  square  miles  with  a  population 
of  2,500,000  in  the  North  of  England,  comes  nearer  to  including  many  of 
the  points  upon  which,  the  Cleveland  Hospital  Council  wished  information 
than  any  survey  reported  in  the  United  States.  This  English  study  which 
was  summarized  in  the  Edinburgh  Medical  Journal  in  December,  1919,  did 
not,  however,  enter  the  field  of  health  administration  or  deal  with  the  social 
and  medical  problems  of  a  large  industrial  city  such  as  Cleveland.  This 
study  is  well  worth  reading  by  hospital  associations  in  this  country,  especially 
such  as  have  to  do  with  rural  and  small  town  community  services  for  the  sick. 


Factors  Determining  Scope 

The  scope  of  a  survey  will  be  decided  by  many  factors,  particularly  by 
the  extent  of  previous  surveys.  Cleveland,  for  instance,  had  adequate  cur- 
rent information  on  recreation,  education  and  housing  and  it  was  unneces- 
sary to  elaborate  upon  these  accessory  features  of  a  health  survey.  Sick- 
ness surveys  had  been  made  in  other  cities  by  the  Metropolitan  Life  Insur- 
ance Company,  the  results  of  which  were  applicable  to  Cleveland,  and  so  it 
was  not  thought  necessary  to  collect  duplicate  data  in  this  field.  The  scope 
of  a  survey  will  also  be  determined  to  some  extent  by  the  aims  of  the  group 
conducting  it,  by  the  special  problems  that  are  immediately  facing  the 
community,  and  by  the  financial  resources  of  the  sponsors  of  the  investi- 
gation. 

In  general,  it  may  be  said  that,  since  many  separate  agencies  both  pri- 
vate and  public  are  involved  in  protecting  or  serving  the  city's  health,  all 
must  be  coordinated  in  an  attack  upon  disease.  As  many  of  them  as  pos- 
sible must  be  analyzed  and  described  in  order  to  arrive  at  a  community 
picture.  The  general  scope  of  the  Cleveland  Hospital  and  Health  Survey, 
as  outlined  in  the  letter  of  authorization,  included: 

1.  Study  of  education  in  medicine  and  in  the  allied  professions. 

2 .  Study  of  the  facilities  for  the  treatment  of  the  sick. 

3.  Study  of  measures  for  the  prevention  of  disease. 

The  scope  of  the  individual  parts  of  the  survey  will  be  decided  again  by 
the  special  community  problems  involved,  as  well  as  by  the  nature  of  the 
institution  or.  service.     As  the  chief  problems  brought  to  the  attention  of 


1008  Hospital  and  Health  Survey 

the  present  survey  lay  along  the  line  of  hospital  and  dispensary  treatment 
these  services  received  a  large  share  of  attention. 

Detailed  plans  of  the  ground  to  be  covered  and  the  character  of  the  re- 
port should,  as  far  as  possible,  be  worked  out  before  the  survey  is  far  ad- 
vanced— for  the  sake  of  economy  in  time  and  money. 


Method  1009 


AIMS  AND  METHODS  OF  DIAGNOSIS  AND  TREATMENT 

The  aim  of  the  community  physician  should  be  not  only  to  arrive  at  a 
diagnosis  and  prescribe  a  course  of  treatment  but  to  explain  thoroughly  both 
diagnosis  and  treatment  to  the  patient,  and  where  possible  to  assure  avoid- 
ance of  repetition  of  the  difficulty.  In  general,  the  Cleveland  survey  has 
been  undertaken  in  a  spirit  of  practical  application  rather  than  as  a  tech- 
nical, statistical  or  research  problem.  That  is,  every  effort  was  made  to  ex- 
plain all  criticisms  and  recommendations  to  the  governing  bodies  and  execu- 
tives of  each  institution  concerned,  as  by  personal  conference  with  these 
groups  the  community  physician  had  his  best  opportunity  for  influencing  the 
family  of  the  patient  to  assist  in  carrying  out  the  treatment  prescribed. 
Often  the  executives  themselves  were  able  to  point  out  deficiencies  that  were 
not  apparent  to  our  investigators.  On  the  other  hand,  they  frequently 
made  situations  clear  that  might,  without  interpretation,  have  given  rise  to 
undeserved  criticism.  Besides  numerous  more  or  less  informal  and  in- 
complete conferences  on  details  of  the  work  during  the  year,  a  week  was 
devoted  to  formal  conferences  with  groups  of  trustees  of  hospitals,  to  present 
and  discuss  the  survey  findings  after  they  had  been  formulated  and  ma- 
tured. The  preliminary  recommendations  and  constructive  criticisms  were 
so  well  received  that  many  recommendations  of  the  survey  had  already  been 
put  into  effect  before  the  findings  were  published. 

The  diagnostic  procedures  employed  by  the  community  physician  are 
similar  to  those  used  by  the  regular  medical  practitioner,  i.  e.,  history  tak- 
ing, physical  examination,  laboratory  analysis. 

Education  of  the  Patient 

It  will  be  necessary  to  make  use  of  educational  methods,  first,  last  and 
always,  to  win  the  confidence  of  the  patient's  family  and  friends.  The 
methods  employed  in  community  education  are  those  of  publicity,  i.  e., 
newspaper  and  magazine  articles,  circular  letters  and  addresses  and  lectures 
by  members  of  the  staff.  It  is  essential  that  the  public  recognize  the  pur- 
pose and  scope  of  the  investigation  and  by  personal  contact  with  the  diag- 
nostic group  develop  confidence  in  those  who  are  conducting  it,  so  that 
when  the  findings  are  ready,  an  educated  and  receptive  public  opinion  will 
have  been  prepared. 

The  Cleveland  Hospital  and  Health  Survey  was  fortunate  in  obtaining 
the  services  of  the  publicity  experts  on  the  staff  of  the  Welfare  Federation, 
who  have  been  most  useful  in  making  contacts  with  the  public  through  the 
local  press. 

During  the  first  month,  the  Survey  sent  form  letters  to  various  groups 
(medical  practitioners,  social  agencies,  hospitals,  labor  unions,  industries, 
men's  and  women's  clubs,  and  fraternal  organizations),  to  obtain  their  in- 
terest and  cooperation.  In  some  cases,  specific  information  was  asked  for 
so  that  the  letters  served  two  purposes.  (For  two  typical  letters,  one  [to 
physicians  and  one  to  social  agencies,  see  Appendix  1  and  2.) 


1010  Hospital  and  Health  Survey 


During  the  course  of  the  Survey  members  of  the  staff  addressed  over 
sixty  meetings  of  various  sizes,  including  the  Academy  of  Medicine,  the 
Men's  and  Women's  City  Clubs,  the  Chamber  of  Commerce,  church  congre- 
gations and  groups  of  physicians,  nurses  and  dentists. 


-j  Community  History  Taking 

In  order  that  the  community  diagnosis  may  be  based  on  all  the  facts, 
and  present  problems  understood  in  the  light  of  the  past,  the  personal  his- 
tory of  the  patient  must  be  secured.  Facts  as  to  the  history  of  public  health 
in  Cleveland  were  obtained  by  conferences  with  those  who  have  been  inter- 
ested in  this  work  for  many  years. 

A  conception  of  the  special  problems  of  the  community  which  rel  ite  to 
public  health,  or  a  knowledge  of  the  history  of  the  present  illness,  must  be 
formulated  from  rather  intangible  material  obtained  in  personal  conferences, 
or  questionnaires  which  ask  specifically  for  criticisms  of  institutions  which 
are  not  serving  the  public  in  a  satisfactory  manner.  The  information  so 
obtained,  although  inconclusive,  will  often  serve  to  suggest  avenues  of  study 
that  might  otherwise  be  overlooked.  Also  an  institution's  relations  with 
the  public  are  an  important  index  of  the  effectiveness  of  its  service.  In 
analyzing  such  information  it  is  important  to  differentiate  criticism  stimu- 
lated by  personal  animosity,  from  that  which  is  confirmed  by  similar  i  obser- 
vations from  other  and  varied  sources,  pointing  towards  a  real  undermining 
of  health  or  at  least  a  defective  structure  or  function. 


Quantitative  Estimate  of  Needs 

It  is  necessary  to  gauge  the  extent  as  well  as  the  quality  of  service  needed 
along  various  lines.  That  is,  an  estimate  must  be  made,  based  on  local  figures 
compared  with  those  from  other  cities,  of  the  number  of  women  who  need 
prenatal  care,  out-patient  delivery  or  institutional  confinement,  the  number 
of  children  of  pre-school  age  who  need  free  medical  supervision,  the  number 
of  tuberculous  who  should  be  under  observation  at  health  centers,  the  num- 
ber and  character  of  those  who  need  dispensary  service,  the  proper  propor- 
tion of  hospital  beds  to  the  population,  and  so  forth.  It  is  obvious  that  no 
final  answers  to  these  questions  can  be  made,  but  in  order  to  decide  the  need 
for  extension  of  the  various  preventive  and  treatment  facilities  the  extent  of 
the  problem  must  be  measured  and  recorded. 

Laws  and  Law  Enforcement 

Study  of  the  adequacy  of  state  and  local  laws  relating  to  the  professions 
and  dealing  with  public  health  agencies,  and  the  efficacy  of  their  enforce- 
ment, is  essential.  In  connection  with  the  mental  hygiene  and  social  hy- 
giene studies  investigations  were  made  also  of  the  provisions  for  detention 


Method  1011 

of  individuals  and  their  treatment  in  the  courts.  Does  the  sanitary  code  of 
the  city  contain  all  modern  provisions  for  health  protection?  Are  the  laws 
adequate  which  regulate  conditions  in  industry  affecting  health?  Compar- 
ing the  existing  laws  with  model  laws  in  other  states  and  cities,  it  will  be 
possible  to  recommend  additions  to  or  changes  in  the  existing  statutes. 

Some  of  the  questions  of  law  enforcement  that  are  fundamental  to  health 
protection  follow:  Are  physicians  and  midwives  practising  without  a  license; 
do  they  report  births,  deaths,  contagious  and  infectious  disease  as  the  law 
requires;  are  housing  and  sanitary  regulations  upheld;  are  children  allowed  to 
work  on  streets  and  in  factories  in  violation  of  the  Child  Labor  laws;  is  the 
ordinance  against  dense  smoke  commonly  observed? 

A  birth  registration  check  was  made  at  the  Division  of  Health  covering 
about  800  children  under  two  years  of  age,  who  had  been  born  in  Cleveland, 
to  see  if  their  births  had  been  recorded.  The  form  on  which  the  information 
for  checking  was  collected  will  be  found  in  the  Appendix  (3). 


Coordination  and  Functional  Control 

The  actual  analysis  of  the  organization  and  accomplishments  of  the 
different  institutions  may  well  be  compared  to  the  physical  examination  of 
the  patient.  It  is  quite  obvious  that  it  is  impossible  to  differentiate  sharply 
the  various  methods  of  procedure,  as  they  often  overlap  or  are  combined. 
In  studying  any  institution  attention  must  first  be  given  to  its  type  of  or- 
ganization and  functional  control  (the  nervous  system).  Of  whom  is  the 
board  of  trustees  composed?  Do  the  trustees  take  a  personal  interest  in  the 
details  of  hospital  administration?  Do  they  see  that  the  same  principles  of 
efficiency  on  which  they  pride  themselves  in  their  private  enterprises  are 
carried  out  in  the  public  institutions  under  their  supervision?  Is  the  execu- 
tive authority  of  the  institution  divided? 

The  organization  of  the  medical  staffs  of  hospitals  and  dispensaries  also 
was  studied  in  detail.  How  is  the  medical  staff  nominated?  How  are  the 
members  appointed?  How  often  are  staff  meetings  held  and  what  is  the 
purpose  of  these  meetings?  Has  the  staff  an  executive  committee?  Is  there 
an  auxiliary  staff?  These  and  similar  questions  were  put,  and  special  recom- 
mendations as  to  hospital  organization  were  made  when  the  answers  were 
obtained. 

The  administrative  procedure  of  private  philanthropic  institutions  is 
very  often  their  weakest  spot.  Methods  of  efficiency  and  practical  economy 
are  often  lost  sight  of  in  well  meaning  attempts  to  render  service. 

Are  purchases  made  in  large  quantities?  Are  storage  facilities  ample? 
Are  cash  discounts  taken?  Are  accounting  and  bookkeeping  methods 
standardized?     Are  all  reasonable  time-saving  devices  in  use?     These  are 


1012  Hospital  and  Health  Survey 

some  of  the  questions  which  interest  the  investigator.     Questionnaires  used 
in 

1.  Study   of  organization   and   administration   of  private   and   public   health 
nursing  agencies 

and 

j 

2.  Study  of  hospital  administration 

are  reproduced  in  the  Appendix  (4  and  5). 

The  Associated  Health  Professions  and  Their  Training 

The  brain  needs  here  as  in  the  case  of  the  individual  patient  the  most 
delicate  and  tactful  approach,  and  the  psychology  of  professional  groups 
must  be  studied,  as  well  as  the  crude  facts  of  their  numbers  and  accomplish- 
ments. As  the  entire  undertaking  of  preventive  medicine  and  all  the  care 
of  the  sick  depend  upon  the  quality  of  licensed  practitioners  of  medicine, 
nursing,  dentistry  and  pharmacy,  full  knowledge  of  the  limitations  in  the 
education  of  students  both  before  and  after  graduation  must  be  sought  and 
described.  If  one  element  rather  than  another  in  the  examination  of  the 
community  has  been  incomplete,  it  is  the  study  of  professional  training  of 
physicians,  dentists  and  pharmacists.  For  the  nurses  the  information  is 
quite  complete. 

Quantitative  Determinations  of  Functions 

It  is  necessary  to  ascertain  the  number  and  the  size  of  the  different  types 
of  institutions  and  to  decide  whether  the  available  service  is  sufficient  to 
meet  the  actual  and  potential  demand.  Are  there  enough  hospital  beds  to 
care  for  the  community  sick?  The  answer  to  this  question  was  sought  in 
various  ways.  The  hospitals  were  asked  to  keep  for  two  months  a  record 
of  the  cases  to  which  they  refused  admission.  Printed  pads  were  furnished 
the  hospitals  on  which  to  record  this  information  (Appendix  6).  The  re- 
sults of  this  investigation  were  tabulated  as  follows : 

Type  of  service — medical,  surgical,  etc. 

Economic  status  of  patient — pay,  part-pay,  or  free. 

By  whom  request  for  hospitalization  was  made — self,  agency,  doctor  or  family. 

Whether  or  not  patient  was  placed  on  waiting  list. 

The  public  health  agencies  were  asked  to  furnish  statistics  as  to  the 
number  of  patients  under  their  care  during  a  certain  month,  who  were 
properly  hospital  cases.  Social  agencies  and  district  physicians  were  asked 
whether  they  were  able  to  obtain  hospital  care  for  their  patients  promptly. 
Questionnaires,  sent  to  physicians,  inquired  whether  they  found  it  difficult 
to  obtain  hospitalization  and  if  so  for  what  class  of  patients.  The  number  of 
available  beds  was  compared  with  the  estimated  population  to  be  served, 
and  comparison  was  made  also  with  the  ratio  of  hospital  beds  to  population 


Method  1013 

in  other  cities.  The  number  of  existing  beds  for  various  special  services, 
e.  g.,  orthopedics,  tuberculosis  and  maternity  was  ascertained  and  a  compari- 
son made  with  the  estimated  need  in  Cleveland  and  with  the  number  of 
beds  available  for  similar  services  elsewhere. 

A  special  investigation  to  determine  the  need,  if  any,  for  an  institution 
to  care  for  convalescents,  was  made  by  visiting  the  homes  of  200  patients 
recently  discharged  from  four  leading  hospitals  to  see  if  conditions  were  proper 
for  their  prompt  convalescence. 

Is  there  enough  social  service  work  provided  by  hospitals  and  dispen- 
saries to  make  the  medical  service  most  effective?  Is  the  ambulance  service 
ample  so  that  the  location  of  hospitals  in  the  outskirts  of  the  city  is  feasible? 
Are  there  enough  dispensaries  and  are  they  properly  located?  Are  the 
special  dispensary  services,  i.  e.,  prenatal,  prophylactic,  babies',  orthopedic, 
industrial,  tuberculosis,  venereal,  and  so  forth,  adequate?  Is  sufficient 
medical  service  provided  by  child-caring  institutions,  by  schools  and  by 
industrial  plants?  Are  there  enough  diagnostic  laboratory  facilities,  both 
public  and  private? 

The  method  of  investigation  to  determine  the  answers  to  these  questions 
was  in  each  case  somewhat  similar  to  that  described  above  for  determining 
the  needs  in  hospitalization.  That  is,  a  study  was  made  of  the  number, 
location  and  amount  of  service  of  the  existing  institutions.  The  question- 
naire that  was  used  in  determining  the  amount  and  character  of  medical 
service  in  industry  is  given  in  the  Appendix  (7).  All  reasonable  avenues  of 
inquiry  were  followed  to  learn  whether  the  local  need  was  being  adequately 
met.  The  amount  of  service  was  compared  with  the  estimated  number  of 
people  to  be  cared  for  and  with  the  extent  of  similar  service  provided  by 
cities  of  approximately  the  same  size.  Hospital  superintendents,  physicians, 
representatives  of  nursing  and  social  agencies  were  asked  by  questionnaire 
and  in  conference,  whether  their  needs  for  ambulance  transportation  were 
being  promptly  and  satisfactorily  met.  Inquiries  were  sent  to  other  cities 
for  facts  as  to  the  number  of  ambulances  provided  by  the  city  hospital,  by 
the  police  and  by  private  hospitals;  as  to  the  number  of  dental  chairs  for 
free  service  and  the  hours  they  were  in  use;  as  to  the  number  of  hours  of 
medical  service  provided  weekly  in  free  clinics  for  the  treatment  of  tuber- 
culosis; and  so  forth.  The  amount  of  potential  dispensary  service  and  of 
medical  service  in  schools  and  industry  is  obviously  determined  not  by  the 
number  of  dispensaries  but  by  the  number  of  physicians  and  nurses  and  the 
amount  of  time  devoted  by  each  to  this  service.  The  actual  amount  of 
service  rendered  is  shown  by  such  records  as  the  number  of  patients  cared 
for  annually  and  the  number  of  different  treatments  given.  Again  the 
value  of  the  service  is  not  measured  by  the  amount  but  rather  by  its  charac- 
ter which  is  a  less  tangible  factor  to  analyze. 

Quality  of  Function 

The  output  of  a  hospital  or  dispensary  cannot  be  measured  by  exact 
standards,  but  there  are  certain  recognized  methods  by  which  medical  and 


1014  Hospital  and  Health  Survey 

nursing  procedure  may  be  analyzed  as  to  quality.  These  are:  a  study  of 
personnel  and  equipment,  an  analysis  of  the  records  of  patients,  a  personal 
observation  of  technic  and  a  statistical  analysis  of  results. 

Upon  the  character  as  well  as  the  training  and  experience  of  the  personnel 
in  charge  of  any  service  depends  the  quality  of  the  product.  Personality  is, 
of  course,  an^intangible  factor  to  evaluate,  but  the  training  and  experience 
of  the  workers  are  or  should  be  a  matter  of  record,  available  to  the  investi- 
gator. In  the  nursing  survey,  and  the  study  of  the  health  department 
especially,  particular  attention  was  given  to  these  factors  (Appendix  8). 
The  employment  of  trained  persons  is  essential  to  assure  standard  service  in 
the  professional  lines.  Inquiry  was  therefore  made  as  to  whether  anaes- 
thetist, dietitian  and  laboratory  technicians  were  employed  in  hospitals. 

In  some  instances  the  character  of  service  must  depend  largely  upon  the 
adequacy  of  equipment.  Laboratory  and  hospital  nursing  technic,  for  in- 
stance, require  certain  minimum  equipment  to  produce  a  high  grade  of 
service.  In  measuring  these  services  observation  was  made  to  see  if  standard 
equipment  was  available.     (Appendix  9.) 

In  order  to  determine  whether  the  physical  defects  of  children  in  insti- 
tutions were  being  detected  and  corrected,  several  hundred  children,  some 
taken  from  each  institution,  received  both  physical  examinations  and  mental 
tests.  For  the  form  used  for  recording  physical  examinations  see  Appendix 
10. 

As  the  records  of  patients  constitute  the  only  means  by  which  an  ob- 
jective presentation  of  medical  work  can  be  accomplished,  the  analysis  of  a 
considerable  number  of  the  records  of  an  institution  gives  a  fairly  accurate 
picture  of  the  clinical  procedure  obtaining  there.  Therefore,  in  evaluating 
the  quality  of  various  professional  services,  the  study  of  records  received 
considerable  attention.  Fifty  records  from  each  of  twenty  hospitals  were 
analyzed  to  find  whether  they  contained  the  following  items:  personal  his- 
tory, physical  examination,  working  diagnosis,  laboratory  findings,  operation 
or  treatment,  progress  notes,  final  diagnosis  and  condition  on  discharge.  One 
hundred  records  were  studied  in  each  of  the  dispensaries  with  the  above 
points  in  mind  and  also  to  ascertain  the  nationality  of  the  patients,  the 
number  of  revisits,  and  so  forth.  Several  hundred  health  records  of  school 
children  were  analyzed  to  find  the  proportion  of  corrections  that  had  been 
made  to  the  number  of  defects  found,  and  the  average  number  of  nurses' 
home  visits  and  parents'  consultations  on  each  case.  Health  center  records 
were  analyzed  to  find  the  average  number  of  patients'  visits  to  the  clinic  and 
of  nursing  visits  to  the  home;  the  records  of  nurses'  time  were  studied  to 
find  the  relative  proportion  spent  in  clerical  and  other  duties.  Prenatal 
records  were  analyzed  to  find  the  month  of  pregnancy  during  which  the 
patient  was  brought  under  care,  as  well  as  the  number  of  patients'  visits  to 
the  dispensary,  and  of  nurses'  visits  to  the  home.  A  comparative  analysis 
of  the  records  of  the  school  census,  of  the  work  certificate  office  and  of  the 
state  industrial  commission  to  learn  the  number  of  children  employed  in 
industry,  was  made.     Data  were  secured  from  a  census  of  100  newsboys 


Method 1015 

attending  a  down-town  school  as  to  their  age,  health,  mental  capacity; — as 
stated  by  their  teachers — and  the  number  of  hours  they  worked  at  might. 
An  investigation  was  made  of  the  content  of  industrial  health  records  and 
the  method  of  compiling  and  analyzing  the  data  recorded.  The  method  of 
filing  and  indexing  hospital  and  dispensary  records  was  also  ^investigated, 
and  inquiry  made  as  to  the  means  of  assuring  compliance  with  thejiospital 
rules  for  the  completion  of  histories. 

Extensive  personal  observation  was  made  of  nursing  service  both  in  hos- 
pitals, dispensaries  and  in  public  health  nursing  districts,  and  of  the  work 
of  school  medical  inspectors. 

In  the  Division  of  Health  also  the  method  of  evaluating  the  quality  of 
service  by  personal  observations  was  found  useful.  Members  of  the  Survey 
staff  accompanied  sanitary  and  dairy  inspectors  and  collectors  of  laboratory 
samples  in  their  trips,  and  made  observation  of  routine  laboratory  examina- 
tions and  other  functions  at  the  central  office. 


Resources  For  Prevention 

In  studying  the  adequacy  of  health  protection  and  the  prevention  of 
disease  the  following  questions  must  be  faced.  Are  sanitary  conditions  in 
child-caring  institutions,  schools  and  industrial  establishments  such  that  the 
health  of  children  and  employes  is  safeguarded?  Is  the  city  water  supply 
from  a  safe  source  and  protected  from  contamination?  Are  sewage  and  gar- 
bage disposal  satisfactory?  Does  the  method  of  control  of  communicable 
diseases  minimize  the  danger  of  their  spread?  Does  the  inspection  of  food 
products  and  drugs  protect  the  public  against  adulterated  or  contaminated 
products?  Are  nuisances  controlled  and  the  contamination  of  the  air  pre- 
vented? Is  the  community  being  constantly  educated  in  the  methods  of 
health  protection,  both  public  and  private? 

The  methods  of  ventilation  and  cleaning,  of  adjustment  of  blackboards 
and  seats,  the  general  construction,  lighting,  cubic  air  capacity  and  toilets 
of  public  school  buildings  were  investigated.  The  temperature  was  read  in 
a  series  of  rooms  and  the  force  of  the  drinking  fountains  in  many  buildings 
was  noted  by  the  investigator.  Investigation  of  working  conditions  was 
made  in  several  hundred  industrial  establishments.  (For  the  questionnaire 
used  in  studying  working  conditions  for  women,  see  Appendix  11.) 

A  study  ofjthe  amount  and  character  of  health  education  was  made 
(for  questionnaire,' see  Appendix  12.) 

Checking  Up  the  Facts  for  Diagnosis 

Statistical  study  may  well  be  compared  with  the  laboratory  method  of 
diagnosis — the  methods^of  investigation  are  more  exact  and  the  findings 
more  definite.  If  the  processes  are  accurate  the  results  permit  certain  de- 
ductions to  be  drawn  with  precision. 


1016  Hospital  and  Health  Survey 

Some  of  the  statistical  studies  made  by  the  Survey  were  as  follows:  A 
study  of  data  regarding  age  and  sex  distribution  and  nationality  of  the  popu- 
lation; a  study  of  general  mortality  and  mortality  from  the  chief  causes  for 
a  period  of  years;  a  comparison  of  mortality  and  morbidity  rates,  as  well 
as  hospital  and  dispensary  attendance,  by  health  districts;  a  study  of  tuber- 
culosis mortality  by  age,  sex,  form  and  occupation;  a  comparison  of  the 
death  rate  under  one  month,  the  maternal  death  rate  and  the  stillbirth  rate 
of  a  series  of  cases  under  prenatal  care  with  that  for  the  city  as  a  whole;  a 
study  of  the  records  of  The  Industrial  Commission  of  Ohio  relating  to 
accident  frequency  and  accident  severity  rates  in  industry  and  to  the  em- 
ployment of  women  and  children  in  industry;  the  preparation  of  pin  maps 
locating  the  various  types  and  sizes  of  industrial  establishments;  a  study  of 
milk  consumption  in  connection  with  the  tuberculosis  survey  (for  the  form 
used  in  collecting  the  material,  see  Appendix  13).  The  records  of  1,000 
families  were  tabulated  as  to  types  of  illness,  amount  of  milk  consumed,  the 
kind  of  milk  purchased  and  how  milk  is  cared  for. 

In  order  to  obtain  statistical  information,  a  census  was  taken  on  Decem- 
ber 3,  1919,  and  again  on  January  15,  1920,  of  the  patients  in  the  hospitals 
of  the  Cleveland  Hospital  Council  and  in  four  other  institutions  which  were 
willing  to  furnish  the  necessary  information.  These  results  were  averaged 
and  tabulated  as  follows:  (Census  blank,  Appendix  14). 

Percentage  of  beds  in  use. 

Type  of  service,  i.  e.,  medical,  surgical,  etc. 

Length  of  stay  of  patients  in  hospital. 

Location  of  residence  of  patients. 

Economic  status  of  patients. 

Percentage  of  cases  admitted  by  staff  and  non-staff  physicians. 

Percentage  of  free,  part-pay  and  pay  cases  admitted  by  staff  and  non- 
staff  physicians. 

Age  of  patients. 

Nativity  of  patients. 

Economic  status  of  patients  according  to  nativity. 

CONCLUSION 

Treatment  and  Follow-up 

When  the  community  diagnosis  has  been  made  and,  after  a  consultation 
of  specialists,  the  method  of  treatment  is  outlined,  how  shall  the  prescrip- 
tion be  prepared,  by  whom  the  operation  be  performed,  and  who  shall  be 
the  victim?  A  detailed  report  of  a  survey  is  of  much  more  than  local  interest. 
Communities  of  comparable  size  have  much  the  same  problems  to  face  as 
has  Cleveland.  Study  of  the  results  of  a  survey  in  one  city  will  often  serve 
to  suggest  the  answer  to  problems  in  another  community. 


Method  1017 

It  was  thought  useful  to  have  the  Cleveland  Survey  printed  in  the  present 
inexpensive  form  in  order  that  copies  might,  at  small  expense,  be  made 
available  to  state  and  local  health  departments,  to  medical  and  general 
libraries,  to  hospitals  and  nursing  organizations,  to  medical  and  other  prac- 
titioners in  the  allied  professions,  to  public  health  societies  and  others. 

The  final  action  of  the  survey  staff  is  to  prepare  their  report  for  publi- 
cation. It  is  left  to  the  patient — the  public — to  do  the  rest.  The  survey 
will  prove  of  no  avail  unless  the  community  is  ready  to  carry  out  the  plan 
proposed.  If,  as  in  Cleveland,  there  is  no  permanent  organization  extant  to 
which  a  follow-up  of  the  community's  case  may  be  left,  it  will  be  necessary 
to  recommend,  as  the  Cleveland  Survey  has  done,  the  formation  of  a  cooper- 
ative group  composed  of  representatives  of  all  organizations  interested  in 
public  health,  to  which — with  their  other  duties — will  be  left  the  task  of 
seeing  that  the  community  takes  its  medicine.  The  proposed  Cleveland 
Public  Health  Association  must  provide  follow-up  and  convalescent  care  for 
the  community  patient,  the  great  city  of  Cleveland! 


1018  Hospital  and  Health  Survey 

APPENDIX 

FORM    LETTERS    AND    QUESTIONNAIRES 

(1.) 

November  28,  1919. 
Dear  Doctor: 

We  are  at  your  service  and  we  need  your  counsel  and  support. 

Take  a  moment  to  answer  the  queries  below  and  we  can  assist  your  patients  through 
you  to  better  service. 

1.  Have  you  found  difficulty  in  obtaining  hospital  care  for  your  own 
patients? 

2.  If  so,  for  what  kinds  of  patients,  i.  e.: 

Surgical  or  medical. 
Pediatric  or  orthopedic. 
Neurological  or  mental. 
Obstetrical  or  gynecological. 

3.  What  solution  have  you  to  suggest  for  remedying  the  hospital  sit- 
uation from  the  point  of  view  of  the  patients  or  of  the  medical  profession? 

4.  During  the  past  12  months,  approximately  how  many  patients  with 
venereal  disease  have  you  had,  under  your  private  care  (syphilis — gonorrhea 
— chancroid)? 

5.  How  many  of  these  patients  discontinued  the  treatment  you  advised 
without  your  consent,  and  why? 

These  reports  will  be  kept  confidential  and  no  names  quoted  in  reporting  the  totals 
received  in  the  answers. 

Come  in  and  watch  the  process  of  taking  the  family  and  personal  history  of  Cleve- 
land, making  the  physical  examination  of  the  city  and  trying  out  laboratory  methods  for 
a  Community  Diagnosis.  It  is  your  community  and  the  treatment  will  be  in  your  hands 
in  any  event. 

Give  us  the  "once-over".     It  does  us  good  to  be  criticized. 

Yours  cordially, 


Director. 

(2.) 

November  20,  1919. 

Dear  Sir: 

The  Hospital  and  Health  Survey  wants  to  look  at  the  medical  and  health  service  of 
Cleveland  from  the  outside  as  well  as  the  inside.  We  need  very  much  to  have  the  infor- 
mation and  opinion  of  the  Social  Agencies.  As  you  call  upon  the  hospitals,  dispensaries 
and  Health  Department  for  medical  aid  in  behalf  of  your  people,  you  can  therefore  give 
us  many  practical  points  which  are  most  important. 

On  a  separate  sheet  we  have  put  a  few  questions  or  topics.  We  should  like  very  much 
to  have  your  answers  or  comments  on  any  or  all  of  these. 


Method  1019 


In  case  you  prefer  to  go  over  the  matter  personally  with  a  member  of  the  staff  of  the 
Survey,  will  you  kindly  cal1  us  so  we  can  arrange  for  a  conference? 

Any  information  given  by  you  as  to  names,  quotations,  etc.,  will  be  treated  as  con- 
fidential by  the  Survey. 

Very  truly  yours, 


GS-JHS  Assistant  Director. 

1.  Patients  refused  admission  to  hospital.  Do  you  find  many  patients  in  whom  you 
are  interested  who  cannot  be  admitted  to  hospitals?  Among  what  classes  are  these  the 
more  frequent?  We  would  be  glad  to  have  comments,  reasons,  etc.,  for  refusal  or  other 
conditions,  which  might  help  to  bring  out  the  nature  or  extent  of  the  shortage  of  hospital 
beds  if  such  exists. 

2.  Have  you  felt  there  is  inadequate  dispensary  service?  If  so,  along  what  lines  of 
work  or  in  what  parts  of  the  city? 

3.  Do  your  agents  find  it  difficult  to  secure  answers  to  inquiries  for  medical  informa- 
tion concerning  hospital  and  dispensary  cases  in  which  you  are  interested?  Are  the  diffi- 
culties uniform  among  different  hospitals  or  dispensaries? 

4.  The  work  of  the  City  District  Doctors.  Are  they  prompt  in  answering  calls? 
Do  they  give  continuous  care  on  your  cases?  Can  you  secure  medical  information  from 
them  when  needed?  Do  you  distinguish  between  the  type  of  patient  you  refer  to  City 
Physicians  and  to  the  other  medical  relief  agencies,  such  as  dispensaries  and  private  doc- 
tors, as  to  whether  they  are  ambulatory  or  bed  ridden,  contagious  or  non-contagious,  etc.? 
Do  you  think  that  patients  who  can  afford  to  pay  anything  for  medical  care  should  be 
referred  to  City  Physicians? 

5.  What  patients  feel  or  say  about  hospitals.  Any  "stories"  or  examples  of  experi- 
ences that  patients  in  hospitals  have  had  which  would  serve  to  bring  out  the  rc-al  difficul- 
ties, needs  or  deficiencies,  would  be  welcome. 

6.  What  policy  exists  between  the  Social  Service  Department  of  the  hospitals  and 
your  agency  with  regard  to  furnishing  material  relief?  What  points  do  the  Social  Service 
Departments  turn  over  to  your  agency  for  general  work  with  the  family  or  how  far  do  they 
carry  this  themselves  or  do  you  both  handle  this  phase  of  the  work  at  the  same  time? 


(3.) 

BIRTH  REGISTRATION  SURVEY 

Fill  out  only  for  children  under  2  years  of  age  born  in  Cleveland. 

Name  of  child  (Family  name) (Given  name). 

Date  of  birth:  Month Day Year 

Place  of  birth  (address  of  residence  or  institution). 

Name  and  address  of  attending  physician  or  midwife, 

Signed  by  person  making  report 


1020  Hospital  and  Health  Survey 

(4.) 

COMMITTEE  FOR  PUBLIC  HEALTH  NURSING  EDUCATION 

OFFICE  REPORT:  PRIVATE  AGENCIES 

A.  I.  Name  of  Association 

Address... j. Year  founded 

B.  Organization 

I.  Types  of  work. 

1  .^General  visiting  nursing. 

(a)  Specify  what  kinds  of  work  are  included .■. 


(b)  What  types  of  sickness  are  refused  or  referred  to  another  organization 
for  nursing  care? 


2.  Specialized  Services 

(a)  Infant  or  child  welfare;  up  to  what  age?. 
Specify  what  kinds  of  work  are  included... 


(b)  Anti-tuberculosis  work Supervision Instruction.... 

Placement Bedside  care. 

(c)  Industrial  nursing 

II.r  1.  Total  number  of  visits  made  during  last  fiscal  year 

2.  Total  number  of  cases 

3.  Cost  of  a  visit 

4.  Average  number  of  visits  per  day  per  nurse 

5.  Number  of  patients  paying: 

(a)  Full  cost 

(b)  Part  cost 

(c)  Nothing 

III.  Personnel 

1.  Board  of  Managers:  Title 

(a)  How  many  are  men? 

(b)  How  many  are  women? _ 

(c)  How  often  does  the  board  meet? — 

(d)  Does  the  nurse  superintendent  meet  with  the  board? 

2.  Nursing  Committee 

(a)  How  many  members? 

(b)  How  often  does  it  meet? 


Method 


1021 


3.  What  committee  determines  policies?... 

4.  What  committee  controls  the  budget?. 


5.  Staff: 

(a)  Superintendent:  Name  and  title 

(b)  Assistant  superintendents,  how  many?. 

(c)  Supervisors, 

(d)  Staff  nurses, 

(e)  Student  nurses,  (graduate) 

(f)  "  "     (undergraduate)  " 

(g)  Attendants  or  practical  nurses, 
(h)  Nurses  employed  in   clerical 

work  (full  time),  "         "      

(i)    Dietitians - 

6.  By  whom  are  the  following  engaged  and  dismissed? 

(a)  Supervisors 

(b)  Staff  nurses._ 

(c)  Clerical  workers.- 

7.  What  are  the  minimum  professional  and  educational  requirements  for  a  Staff 

position? 

8.  Are  staff  nurses  assigned  to  special  services?     Describe: 

C.  Administration 

I.  Supervision 

1.  Number  of  staff  nurses  to  afield  supervisor:  minimum maximum 

2.  How  often  do  staff  nurses  report  to  the  supervisor  in  the  main  or  branch  office 

or  station? _ - 

3.  Does  the  supervisor  visit  in  homes,  (a)  with     the  staff  nurse? 

(b)  without  "      "         " 

4.~Are  printed  or  written  standard  practice  instructions  used? 

II.  Conferences 

1.  Are  meetings  of  entire  staff  held  regularly? (a)  How  often? 

(b)  Who  calls  the  meeting? (c)  Who  presides? 

(d)  Who  attends? 

2.  Are  case  conferences  held  regularly? (a)  How  often? 

(b)  Who  presides? (c)  Who  attends? 

3.  What  conference  of  other  organizations  are  regularly  attended  by  members 

of  the  staff? 


102c2  Hospital  and  Health  Survey 

III.  Efficiency 

1.  What  methods  are  used  to  judge  efficiency  of  nurses? _..__.__ 


2.  (a)  Are  efficiency  records  kept? (b)  Has  the  nurse  access  to  her 

record? _ 

(c)  'If  not,  how  is  the  nurse  informed  of  her  standard? 

IV    Salaries 

1.  Staff  nurses:  Minimum Maximum Rate  of  increase 

2.  Supervisors:  "        " "       "       "        

3.  What  is  the  length  of  vacation  on  salary?....... 

4.  Are  the  following  furnished  in  addition  to  salary?: 


(a)  Uniforms (b)  Board (c)  Lodging 

(d)  Other  Allowance 


V.  Hours  of  work 

1.  What  are  the  hours  of  work  daily? (a)  Sunday? 

2.  Is  time  spent  in  record  keeping  included  in  working  day?... 

3.  Is  there  one  complete  day  of  rest  in  seven? 

4.  Is  there  a  weekly  half-holiday  in  addition? 

5.  Overtime  work:  average  per  week  per  individual  during  last  month 

6.  Is  night  work  expected?     (a)  For  what  cases?.- 

_ (b)  Is  time  off  allowed  for  night  work?. 

VI.  Recording 

1.  How  many  hours  weekly  are  spent  in  recording,  (a)  by  supervisor? 

(b)  by  staff  nurse? 

2.  How  many  clerical  workers  (not  nurses)  are  employed? 


D.  What  is  the  superintendent's  conception  of  the  function  of  the  Association  in  regard 

to  the  education  of 

(a)  Patients  and  families? _ 

(b)  Nurses? 

E.  Comment  by  superintendent  on  education,  training,  and  personalty  of  staff  nurses? 


F.  Obtain  two  copies  of  the  following: 

1.  All  record  forms. 

2.  Practice  instructions. 

3.  Efficiency  record. 

4.  Annual  report  for  last  two  years. 

5.  Publicity  material  published  within  the  last  year. 


Method  1023 


G.  Remarks: 


Name  of  Investigator. 
Date.. 


(5.) 

SURVEY  OF  ADMINISTRATIVE  DEPARTMENTS  OF  CLEVELAND   GENERAL 

HOSPITALS 

FINANCIAL  ADMINISTRATION 

(a)  Per  capita  per  diem  cost  of  administration — 1918? ..1919? 

Do  you  charge  all  expenditures  for  current  repairs,  new  equipment  and  betterments 
to  expense  account  so  that  it  will  appear  in  your  per  capita  per  diem  cost  of  main- 
tenance?  

Do  you  charge  off  annually  a  percentage  for  depreciation?... 

(b)  Do  you  discount  certain  bills  for  cash?  

Total  earnings  from  cash  discounts  for  1919? 


(c)  Have  you  an  income  from  endowments? 

(d)  What  rate  charged  for  private  rooms? Ward  beds? 

(e)  Do  you  charge  extra  for  the  following? 

Blood  transfusion? Rate? 

Large  surgical  dressings? ._ Rate? 

X-Ray  plates  and  stereoscopic  examinations? Rate? 

Nurses'   board? Rate? 

Surgical  dressings,  such  as  perineal,  abdominal  and  prostatic  pads,  plaster 

bandages,  etc.? Rate? 

Plaster  casts? Rate? 

Services  of  anesthetist?..... Rate? 

All  laboratory  examinations? Rate? 

Fancy  foods,  such  as  squabs,  broilers,  frog  legs,  etc.? .....Rate? 

First  aid  services  in  emergency  cases? Rate? 

Salvarsan  administration? _ Rate? 

Drugs  and  prescriptions? Rate?.... 

Splints  and  surgical  appliances? Rate? 

Ambulance  services?. Rate? 

Meals  and  cots  for  relatives  and  friends  of  patient? Rate? 

(f)  Do  you  collect  board  and  room  accounts  one  week  in  advance? 

Do  you  bill  patient's  responsible  relative  weekly  thereafter? 

(g)  Have  you  an  office  clerk,  investigator  or  credit  man  for  investigating  financial  stand- 

ing of  patients? 


1024  Hospital  and  Health  Survey 


(h)  Do  you  admit  county  or  city  patients  at  regular  rates? 

(i)    Do  you  use  a  budget  system  in  estimating  your  expenses  for  the  ensuing  year? 
(j)   Do  you  have  an  annual  accounting  by  a  firm  of  accountants? 


Have  you  installed  a  modern  bookkeeping  system  adapted  to  hospitals? 

If  a  standardized  system  of  hospital  bookkeeping  and  financial  reports  were  recom- 
mended, would  you  endeavor  to  have  same  carried  out  in  your  hospital? 

Have  you  an  accounting  system  in  use  in  your  hospital? 


PURCHASES  AND  SUPPLIES 

(a)  Are  all  purchases  made  by  or  with  the  personal  approval  of  the  superintendent?. 

Have  you  a  steward  who  makes  purchases? 

Are  heads  of  departments  permitted  to  make  purchases? 


(b)fHave  you  saved  money  through  the  purchasing  bureau  of  the  Cleveland    Hospita 


Council?. 


(c)  Do  you  obtain  quotations  or  ask  assistance  of  the  purchasing  bureau  of  the  Cleveland 

Hospital   Council  when  about  to  make  purchases  of  any  size? 

Can  you  increase  the  amount  of  your  purchases  through  the  bureau  to   advantage? 

(d)  Have  you  sufficient  store  room  capacity  for 

One  year  supply  of  canned  goods? 

Three  to  six  months  of  gauze  and  cotton?.. 

Three  to  six  months  soap  supply? 

Three  to  six  months  supply  of  dry  goods? 


(e)  Do  you  store  fresh  eggs  or  fresh  butter  in  public  refrigerator  storage  house  in  April  or 

May  for  use  during  the  period  of  maximum  high  prices?  (November,  December, 
January) 

(f )  Have  you  contracts  for  the  purchase  of  coal? Electric  lamps? 

Milk  from  producers? 

(g)  Would  you  cooperate  with  the  Cleveland  Hospital  Council  and  the  American  Hospital 

Association  in  a  standardization  of  hospital  supplies?. 

HOSPITAL  ECONOMICS,  SALVAGING,  ETC. 

(a)  Have  you  a  house  carpenter? Steamfitter?..... 

Painter? 


(b)  Have  you  a  surgical  appliance  or  instrument  repair  shop? _ 

Do  you  salvage,  wash,  and  reclaim,  gauze  and  bandages?..... 

Do  you  bail  and  sell  waste  paper? 

Grease? Garbage? Barrels? Old  Rubber?. 

Old  metal? Rags? Bottles? 


Method  1025 


(c)  Do  you  make  soft  soap  from  grease? From  soap  chips? — 

(d)  Do  you  utilize  labor-saving  devices? 

Vacuum  cleaner? 

Electric  floor  scrubber? 

Electric  dough  mixers,  meat  cutters,  etc.? 

Dish  washing  machines? 

(e)  Do  you  maintain  a  sewing  room  and  manufacture  part  of  your  dry  goods?. 

DEPARTMENTAL  EXPENSES 
Engineering  Department 

(a)  Do  you  manufacture  your  own  electric  current? 

(b)  Is  your  boiler  plant  and  machinery  up-to-date? 

(c)  Do  you  maintain  a  refrigerating  plant? 

And  are  your  ward  and  corridor  ice  boxes  refrigerated  therefrom? * 

(d)  Do  you  manufacture  ice? - 


Laundry 

(a)  Is  your  laundry  machinery  in  good  order  and  modern  in  type? 

(b)  Have  you  a  steam  tumbler? Steam  presses? 

(c)  Have  you  a  trained  laundry  man  or  woman  in  charge? 

(d)  Do  you  manufacture  your  laundry  soap  from  soap  chips  or  grease  and  alkali?. 

Ambulance 

(a)  Do  you  maintain  a  hospital  ambulance  service? --— 

If  not,  what  ambulance  do  you  utilize? 

(b)  Do  you  consider  the  Cleveland  ambulance  service  satisfactory? 

(c)  Should  a  central  ambulance  service  be  managed 

By  the  municipality? 

By  private  ownership? - 

By  the  Cleveland  Hospital  Council? 


Dietetic  Department 

(a)  Have  you  a  dietitian? 

(b)  Does  she  arrange  all  menus  for  patients,  nurses  and  employes? 

(c)  Does  she  have  general  supervision  of  all  cooking  and  food  service  in  the  hospital?. 


1026  Hospital  and  Health  Survey 

(d)  Does  your  dietitian  purchase  food  supplies? 


Professional  and  Staff  Service 
(a)  Have  you  an  organized  Attending  Staff? 


(b)  Has  the  Attending  Staff  an  Executive  Committee  with  authority  in  professional  mat- 

ters?  .1 , 

(c)  Is  the  Superintendent  a  member  of  the  Executive  Committee? _ 

(d)_Do  you  furnish  rubber  gloves  for  your  attending  surgeons  for  use  on  private  cases? 
— If  so,  why? 


(e)_Do  you  purchase  manufactured  catgut,  or  do  you  prepare  your  plain  and  chromic 
catgut  from  raw  gut? _ 

(f)  Has  any  member  of  your  Attending  Staff  authority  to  purchase  equipment  or  sup- 
plies?  


(6.) 

APPLICANTS  FOR  HOSPITAL  CARE  NOT  ADMITTED 

Name  of  Hospital _ 

Date __ 

Sex. _ .Age 

Nature  of  disease  (or  diagnosis) 

Address  (or  location  in  city) 


Was  applicant  for  Free Part  Pay Pay. 

(Check) 

Was  request  for  admission  made_by  Patient's  self. 

Family  of  patient 


Agency  in  behalf  of  patient. 
(Check) 


If  request  by  agency,  please  state  name  of  agency. 

Was  applicant  put  on  waiting  list 

Name  of  organization  giving  information 


(7.) 

MEDICAL  SERVICE  IN  INDUSTRIAL  ESTABLISHMENTS 

1.  Firm  name Date 

2.  Address 


Method  1027 

3.  Nature  of  product 

4.  Total  number  of  employes Male Female Children,  15-18 

5.  Medical  Service 

Dispensary Location  in  plant No.  rooms , Size 

Plant  hospital No.  beds Personnel 

Physicians,  full  time,  during  service Part  time 

Names  and  addresses - 

Nurses,  trained,  male,  female 

No   on  dressings,  visiting,  other,  mixed 

Type  of  medical  service 

First  aid Kits  where? 

Average  no.   dispensary  visits  daily.— 

Total  no.   accident  cases  per  month Surgical,  n.  o.  s Medical 

Accessibility  of  disp.  Verbal,  written  permission  of  foreman 

Noon  visits? ~ After  working  hours On  company  time? 

Physical  examination,  required,  optional,  applicants,  employes,  periodic,  transfers? 


Causes  and  percentage  rejections 

No.  handicapped  employed... Own  employes? 

Medical  records,  day  sheet 

Permanent  individual  record : 

Daily  individual  record _. 

Special  services 

Dental  service Limits... Cost 

Laboratory. X-Ray 

Visiting  nursing — 

Absence  follow-up ....Sickness. 

Dressing  assistants Clerks. 

Interpreters 

Ambulance  service,  own.. equipment,  personnel — 

Hospital  for  severe  cases 

Service  satisfactory?. Why? 

Contract? Supplementary  compensation? 

Complaints? 

Do  you  favor  establishment  of  industrial  wards? 

Of  industrial  clinics? : — 

Care  of  eye  injuries? 

No.  cases  tuberculosis  yearly Disposal 

Disposal  communicable  diseases 

Venereal  disease  program 


1028  Hospital  and  Health  Survey 

6.  Relations  of  medical  department. 

To  whom  is  chief  surgeon  responsible? 

To  whom  are  nurses  responsible? 

Relation  to  employment _ 

Relation  to  safety 

Relation  to  other  employes'  services. 

7.  Personal  Service  Activities 

Mutual  benefit  fund Control 

Self  insurance Sick  benefit 

Sick  absences Accident  absences 

Rest  rooms Equipment 

Lockers Location 

Lunch  room Food  sold,  heated 

Recreation 

Education,  health,  general „ 


8.  Health  hazards  of  operation. 


9.  Labor  unions _ 

Shop  committees 

10.  Cost  of  medical  service Salaries - Equipment- 
Maintenance 

Does  it  pay?     How?. 

1 1 .  Information  from Position 


12.  Statistical  reports. 

Record  forms 

Photographs 

Blue  prints 


Method 


1029 


(8.) 

COMMITTEE   ON  PUBLIC  HEALTH  NURSING   EDUCATION;    INDUSTRIAL 

NURSING  SERIES 

PERSONAL  HISTORY 


A.  1 .  Name  and  Address  of  Employer.. 


2    Name  of  Nurse 3.  Age..... 4.  M.  S.  W — 

5.  Are  you  registered? 6.  If  so,  give  state  and  year 

7.  Name  of  present  position  (specify  staff  nurse,  supervisor,  head  nurse,  assistant,  etc.) 


8.  Length  of  service  in  present  position. 


.years months. 


B.  1.  Did  you  hold  a  paid  position  before  beginning  nurses'  training?. 
(Describe  last  two  positions  only) 


Nature  of  Work* 

Length  of  Service 

Years 

Months 

*Specify  exact  position  held,  e.  g.,  teaching,  clerical  work;  employment  in  store  or  factory  other  than 
clerical;  personal  service,  such  as  caring  for  children,  social  work,  etc. 

2.  Paid  positions  held  after  completing  nurses'  training — 

Have  you  done  private  nursing? If  so,  for  how  long? years 

months. 

Positions  other  than  private  nursing — 


1030 


Hospital  and  Health  Survey 


Name  of  Employer 

Place 

Nature  of  Work* 

Length  of  Service 

Association,  Company 
or  Individual 

City  or  Town 
and  State 

Yrs. 

Mos. 

■J 
(a) 

(b) 

(c) 

(d).. 

(e) _ 

(f) 

*Give  name  of  position  and  kind  of  work  ,  e.  g.,  head  nurse;  operating  room;  staff  nurse;  infant  wel- 
fare work,  etc 


C.  1.  General  Education 


NAME 

City  or  Town 
and  State 

Year  of 
graduation 

If  not  grad- 
uate No.  of 
yrs.  attended 

Grammar   or  Par- 
ochial School 

High  School          

College.. 

Other  Schools  Not 
Nurses'    Training 
Schools 

2.  Hospital  Training  (Undergraduate): 

Name  and  Address  of  Nurses'  Training  School. 


Year  of  Graduation Length  of  Course. 

Numb_r  of  Hospital  beds  at  time  you  graduated 


Method 


1031 


Were  pupils  sent  out  of  hospital  to  do  private  nursing? 

If  so,  for  how  long  were  you  thus  employed? 

Did  your  training  include  work  with  the  following: 

(a)  Men (b)  Women (c)  Children 

(d)  Sick  Infants  under  2  yrs (e)  Medical  Cases 

(f)    Surgical  Cases (g)  Obstetrical  Cases 

(h)  Nervous  and  Mental  Cases (i)  Venereal  Diseases 

(j)    Tuberculosis (k)  Other  Communicable  Diseases  (specify 

which) ..... 


3.  Postgraduate  Courses: 


School  or  College 

City  and  State 

Length  of 

Time 
Attended 

Year 

Subjects  Studied 

Nurses'  organizations  of  which  you  are  a  member: 


Date. 


1032  Hospital,  and  Health  Survey 

(9.) 

WARD  EQUIPMENT 

Service  Rooms — 

1.  Bathroom:     (a)  Is  it  clean? (b)  Adequate  facilities? ,,  

2.  Utility  Room:     Are  the  following  present  and  adequate? 

Slop  hopper. Instrument  sterilizer 

Utensil  sterilizer If  not,  what  is  done  in  usual  cases? 

Bedpan  and  stool  sterilizer 


If  not,  what  is  done  in  usual  cases? In  infectious  cases?. 


In  infectious  cases? Gas  burner 

Cans  for  rubbish 

Sink Linen  hampers Chests. 

Bedpan  hopper Table „ Shelf—. 

Care  of  infectious  linen , 


3.  Portable  Equipment — Is  it  adequate? 

Basins :     Cleaning Thermometers 

Bathing Tray  treatment  system 

Hot  water  bags 

Ice  caps._ Provision  for  medication. 

Rubber  rings 

4,  Diet  Kitchen: 


Sink Gas  or  electric  plate 

Ice  chest Dish  sterilizer 

Steam  table Trays  and  equipment  of  same: 

Excellent Good Fair Poor 

5.  Linen  Closet: 

Supply  of  linen Arrangement Cleanliness 

6.  Broom  or  Maids' Closet:     Hopper Condition  of  brooms  and  mops. 


Method  1033 

(10.) 

MEDICAL  EXAMINATION  OF  CHILDREN  IN  INSTITUTIONS 

Institution 

Address — 

Name ^ Age 

Date  of  Admission 


Date Height Weight. 

1.  Vision:     OD 

OS 

2.  Hearing 

3.  Defective  Teeth:     Primary 

Permanent 

4.  Defective  Nasal  Breathing... 

5.  Hypertrophied  Tonsils 

6.  Defective  Nutrition._ 

7.  Cardiac  Disease :     Functional 

Organic 

8.  Pulmonary 


9.  Orthopedic  Defect.. 

10.  Nervous  Disease.... 

1 1 .  Miscellaneous 


(11.) 

INDUSTRIAL  DIVISION 
Women  and  Industry  Questionnaire 

Firm Address 

Product 

1.  Number  Employes  (on  production) — 

Male 

Female 

Boys  15  to  16_ 

Girls  16  to  18 

2 .  Regularity  of  employment 

3.  Transportation... 

4.  Hours:  to Lunch to Saturday to. 


1034 


Hospital  and  Health  Survey 


Maximum  daily Total  weekly Overtime 

5.  Night  work : ; 

6.  Women  first  employed „ 

7.  Operations  found  unsuitable  for  women  and  why 

8.  List  of  operations  now  performed  by  women.     Check  those  on  which  women  replace 
men. 


Operation 

No.  Employes 

Wage  rate 

■ 
Piece  or  TimeWork 

Wkly.  earnings 

\9.  Comparison  with  men  or  boys  on  same  work  as  to  wage  and  efficiency 

10.  Minimum  or  guaranteed  wage 

11.  Work,  how  learned — Training  school,  forelady,  other  workers 

1 2 .  Opportunities  for  advancement _ 

13.  Types  of  women  workers — nationality,  color,  age,  civil  state 

Educational  requirement, 

Male  Female 

14.  Absences 

Lates... 

1 5 .  Length  of  service 

Transfers 

16.  Accident  incidence 

Sickness  incidence 

17.  Medical  service 

Hospital  used 

Home  visits ; 

18.  Supervision  of  women  by Extent 

Employment  woman 

Doctor  (M.  F.  full,  part  time) Hours 

Nurse 

Service  worker.. 

Forelady 

19.  Working  conditions 

(a)  Type  of  building , 

(b)  Ventilation 

(c)  Cleanliness : 

(d)  Sanitation 

(e)  Light 

(f)  Distribution  of  women Crowding 

(g)  Standing.. Chairs 


Method  1035 


(h)  Lifting _ 

(i)    Fatiguing  movements 

(j)    Special  health  hazards 

(k)  Lockers,  dressing  room 

(1)    Uniforms,  optional,  required,  provided laundered type- 
Cm)  Couches 

(n)  Lunch  room Food  sold,  heated 

(Rest  Periods) 

20.  Physical  examination,  partial,  complete,  applicants,  employes,  periodic,  transfers. 
Care  of  pregnant V.  D 

21.  Health  education.. vs.  special  hazards 

Safety  instruction 

22.  Vacations 

23.  Recreation 

24.  Benefit  association 

25.  Shop  committee.     Union... 

Information  from By Date- 
Comment: 


(12.) 

PUBLIC  HEALTH  EDUCATION 

Name  of  Organization 

Type  of  education  given — Anti-tuberculosis 

Social  Hygiene _ 

Etc 

Way  information  given — 

Literature 

Lectures 

Etc... 

How  many  people  reached? .... 

What  age  and  sex  reached? 

Any  racial  adaptation? 

Consistent  or  spasmodic  effort? 

Conception  of  future  activity  along  this  line? 

Samples  of  literature 


(13.) 

MILK  CONSUMPTION  SURVEY 

Date  of  visit ..... 

Nationality  (7) No Street Agency  visiting  (1). 

Family  receiving  relief  (2)  yes no Kind  of  relief  (3) _ 

No.  in  family:  (4)  Adults  (15  and  over) Lodgers..... 

Children  (6-14  incl.) .Children  under  6 

Illness  in  family  at  time  of  visit  (8) 


1036  Hospital  and  Health  Survey 


Members  (6)  Nature  of  Illness 


Milk:  Daily  amount  (qts.) Bottle Bulk Canned  (5) Otherwise. 

Check 

Kept  cold Covered 


Is  it  pasteurized:  by  dealer or  at  home is  it  certified?. 

Check 


Remarks: 


Investigator.. 


1.  Initials  only 

2.  Other  than  home  nursing  care. 

3.  Financial,  clothing,  food,  medical  care,  etc. 

4.  Include  any  relative  living  in  family  as  adults  or  children  as  case  may  be. 

5.  Condensed — evaporated,  etc. 

6.  Mother,  lodger,  etc.,  call  all  persons  14  and  under,  children. 

7.  Be  particular  to  specify  negroes. 

8.  Include — (a)  Sickness  requiring  the  attention  of  physician,   (b)   Sickness  requiring  treatment   at 
hospital  or  dispensary,  (c)  Sickness  preventing  work,  (d)  Sickness  preventing  attendance  at  school. 


Method 


1037 


h 

■    o  x 
"I 

> 

TO 

2 

to 

> 

a 
a 

- 

Pay, 

Free  or 

Part  Pay 

Type  of  ward 
(medical,  sur- 
gical, etc.) 

0 

5 
era 
3 
0 

0 
% 

SB 
rr 

c 

a 

0 
■-h 

0 

n> 
0 

CO 

No.  of  days 
already  in 
Hospital 

n 

On  i 

B<< 

1038  Hospital  and  Health  Survey 

Bibliography  01  Surveys 

By  Julia  T.  Emerson 
HEALTH  ADMINISTRATION  SURVEYS 

UNITED  STATES 

Harmon,  G.  E.  A  comparison  of  the  relative  healthfulness  of  certain  cities  in  the 
United  States  based  upon  the  study  of  their  vital  statistics.  American  Statistical 
Association,  Quarterly  Publication  v.  15  no. 114  pl57-174  June  1916. 

Lumsden,  L.  L.  Rural  sanitation;  a  report  made  in  15  counties  in  1914,  1915,  1916. 
Treasury  Department,  U.  S.  Public  Health  Service,  Public  Health  Bulletin  no.94, 
1918.     336p. 

Schneider,  Franz,  jr.  A  survey  of  the  activities  of  municipal  health  departments  in 
the  United  States.  (Begun  August  1913)  Russell  Sage  Foundation.  Reprinted 
American  Journal  Public  Health  v.6  no.l    January  1916. 

Warren,  B.  S.  and  Sydenstricker,  Edgar.  Statistics  of  disability;  a  compilation  of 
some  of  the  data  available  in  the  United  States.  U.  S.  Public  Health  Service 
Public  Health  Reports  v.  31  no.16  p989-999  April  1916. 

ALASKA 

Haines — Craig,   H.   M.   and  Lambie,  J.   M.     Medical  survey  of  an  Indian  village. 
Military  Surgeon,  July  1914     pi  1-16. 

COLORADO 

Fox,  Carrol.  Public  health  administration  in  Colorado.  Reprint  383,  U.  S. 
Public  Health  Service,  Public  Health  Reports,  December  1916,  p3485-3520. 

CONNECTICUT 

Middletown — Greenberg,  David  and  Joel,  I.  D.     Health  survey,  under  direction  of 
C-E.  A.  Winslow,  1918.     73p. 

New  Haven — Fisher,  Irving.     Health  of  New  Haven.     New  Haven  Civic  Federation 
1913.     8p. 

FLORIDA 

Fox,  Carrol.  Public  Health  administration  in  Florida.  Reprint  340,^U.  S.  Public 
Health  Service,  Public  Health  Reports,  June  2,  1916,  pl359-1407. 

GEORGIA 

Atlanta — Lindholm,  S.  G.     Report  of  survey  of  the  Department  of  Health.     New 
York  Bureau  of  Municipal  Research,  191 2.     44p. 

Atlanta — Schneider,   Franz,  jr.     Survey   of  the   public    health    situation.      Atlanta 
Chamber  of  Commerce,  1913.     22p. 


Bibliography  1039 


ILLINOIS 

Grubbs,    S.    B.     Public   health   administration   in    Illinois.     Reprint    275,     U.     S. 
Public  Health  Service,  Public  Health  Reports,  May  21,  1912. 

Mathews,  J.  M.     Report  on  public  health  administration.     State    Efficiency    and 
Economy  Committee,  Springfield,  Illinois,  1914.     54p. 

Chicago — Perry,  J.  C.  Public  health  administration  in  Chicago.  U.  S.  Public 
Health  Service,  Public  Health  Reports  v.30  p2536-2561  August  27,  1915. 

Freeport — Sanitary  and  health  survey  of  the  city  of  Freeport;  conducted  by  Depart- 
ment of  Public  Health  in  cooperation  with  civic  organizations  of  Freeport.  Super- 
vised by  P.  L.  Skoog.     Illinois  Health  News  v.4  n.  s.  no. 5  p75-106  May  1918. 

Quincy — Fox,  Carrol  Public  health  administration  in  Quincy.  Reprint  428,  U.  S. 
Public  Health  Service,  Public  Health  Reports,  October  5,  1917,  pl665-1679. 

Springfield — Palmer,  G.  T.  Sanitary  and  health  survey.  Reprint  from  Academy 
of  Political  Science  Publications  v.2  no.4  1912.     50p. 

Springfield — Schneider,  Franz,  jr.  Public  health  in  Springfield.  Russell  Sage 
Foundation,  Department  of  Surveys  and  Exhibits,  1915.     159p. 

White  County — Foster,  I.  A.  and  Fulmer,  Harriet  Health  survey  of  White  County; 
made  under  auspices  of  Illinois  State  Board  of  Health  and  Illinois  State  Associa- 
tion for  the  Prevention  of  Tuberculosis.      Springfield  Board  of  Health,  1915.     23p^ 

INDIANA 

East  Chicago — Hendrich,  A.  W.  Public  health  in  East  Chicago.  East  Chicago 
Department  of  Health,  1916.     42p. 

South  Bend — Fox,  Carrol  Public  health  administration  in  South  Bend.  U.  S. 
Public  Health  Service,  Public  Health  Reports  v.32  p776-805  March  25,  1917. 

KANSAS 

Sumner  County — Sumner  County  sanitary  and  social  survey.  Kansas  State 
Board  of  Health  Bulletin  v.9  no.5  May  1915. 

Topeka — Schneider,  Franz,  jr.  Public  health  survey  of  Topeka.  Russell  Sage  Foun- 
dation, Department  of  Surveys  and  Exhibits,  1914.     98p. 

KENTUCKY 

Crane,  Mrs.  C.  J.  (B)     Sanitary  conditions  and   needs   of  Kentucky.      Kentucky 
Medical  Journal  v.7  no.13  August  1,  1909.     44p. 

MAINE 

Lewiston  and  Auburn — Pratt,  A.  P.  Public  health  administration  in  Lewiston 
and  Auburn;  a  report  of  a  survey  made  under  direction  of  the  State  Department 
of  Health  for  Public  Health  District  Health  Officer,  Augusta.  State  Department  of 
Health  Bulletin  v.l  n.  s.  nos.10-11  pl51-170  October-November. 


1040  Hospital,  and  Health  Survey 

Portland — Pratt,  A.  P.  Public  health  administration  in  Portland;  a  report  of  a 
survey  made  under  the  direction  of  the  State  Department  of  Health.  State  De- 
partment of  Health  Bulletin,  v.l  n.  s.  no.3  p58-75  March  1918. 

MAR  YLAND 

Fox,  Carrol  Public  health  administration  in  Maryland.  Reprint  166,  U.  S. 
Public  Health  Service,  Public  Health  Reports,  January  30,  1914.     80p. 

Baltimore — Fox,  Carrol  Public  health  administration  in  Baltimore.  Reprint  201, 
U.  S.  Public  Health  Service,  Public  Health  Reports,  June  12,  1914.     80p. 

MASSACHUSETTS 

Springfield — McCombs,  C.  E.  Organization  and  administration  of  the  health  de- 
partment of  Springfield.  Springfield,  Bureau  of  Municipal  Research,  1914.  48p. 
(o.  p.) 

Taunton  and  Quincy — Horowitz,  M.  P.  A  synoptic  report  on  a  comparative 
sanitary  survey  of  two  Massachusetts  cities.  Reprint,  American  Journal  of 
Public  Health  v.7  no.8  p698-711.  Sanitary  Research  Laboratory  of  Massachu- 
setts Institute  of  Technology,  Cambridge,  Massachusetts. 

MICHIGAN 

Ann  Arbor — Folin,  J.  W.  Health  survey.  U.  S.  Public  Health  Service,  Public  Health 
Reports  v.4  n.  s.  p536-539  October  1916. 

Saginaw — Crane,  Mrs.  C.  J.  (B)  Sanitary  survey  of  Saginaw.  1911.  Kalamazoo, 
Michigan.     The  author.     42p. 

MINNESOTA 

Crane,  Mrs.  C.  J.  (B)  Report  on  a  campaign  to  awaken  public  interest  in  sani- 
tary and  sociologic  problems  in  the  state  of  Minnesota.  State  Board  of  Health, 
1911.     239p. 

Fox,  Carrol  Public  health  administration  in  Minnesota.  Reprint  223,  U.  S. 
Public  Health  Service,  Public  Health  Records,  October  2,  1914. 

Minneapolis — Biggs,  H.  M.  and  Winslow,  C-E.  A.  Ideal  health  department. 
Minneapolis,  Civic  and  Commerce  Association,  1912.     36p.     (o.  p.) 

St.  Paul — Efficiency  and  next  needs  of  St.  Paul's  Health  Department.  New  York 
Bureau  of  Municipal  Research,  1913.     48p. 

St.  Paul — Flint,  E.  M.  and  Aronovici,  Carrol  Health  conditions  and  health  service 
in  St.  Paul.     Amherst  H.  Wilde  Charity,  1919.     lOp. 

St.  Paul— Young,  G.  B.  Public  health  administration  in  St.  Paul.  U.  S.  Public 
Health  Service,  Public  Health  Reports  v.32  no.2  p41-71  January  12,  1917;  and 
2d  U.  S.  Public  Health  Service,  Public  Health  Reports  v.32  no.3  p99-138  January 
19,  1917. 


Bibliography  1041 

MISSOURI 

St.  Joseph — White,  J.  H.  Report  of  a  sanitary  survey  of  St.  Joseph.  Reprint  185, 
U.  S.  Public  Health  Service,  Public  Health  Reports,  August  24,  1914. 

NEBRASKA 

Fox,  Carrol  Public  health  administration  in  Nebraska.  Reprint  348,  U.  S. 
Public  Health  Service,    Public    Health   Reports  v.31  no.27  pl750-1775  July  1916. 

NEVADA 

Fox,  Carrol  Public  health  administration  in  Nevada.  Reprint  317,  U.  S.  Public 
Health  Service,  Public  Health  Reports,  December  31,  1915,  p3802-3823. 

NEW  JERSEY 

Glen  Ridge — Horowitz,  M.  P.  Sanitary  survey  of  the  Borough  of  Glen  Ridge. 
Massachusetts  Institute  of  Technology,  Department  of  Biology  and  Public  Health, 
1916.     41p. 

Hoboken — Sanitary  survey  of  Hoboken.  New  York  Bureau  of  Municipal  Research, 
1913.     31p. 

NEW  MEXICO 

Kerr,  J.  W.  Public  health  administration  in  New  Mexico.  U.  S.  Public  Health 
Service,  Public  Health  Reports   v.33  no.46  pl976-1995  November  15,  1918. 

NEW  YORK 

Report  of  special  public  health  commission,  Albany,  New  York,  1913.     36p. 

Durbea,  C.  J.  Preliminary  inquiry  into  the  health  needs  of  rural  people  of  the 
state  of  New  York.  36th  Annual  Report  of  State  Department  of  Health  v.3 
p79-138  December  31,  1915. 

Amsterdam — Terry,  C.  E.  and  Schneider,  Franz,  jr.  Report  of  health  inventory  of 
the  city  of  Amsterdam,  1917.     lip.     (Delineator  7th  Baby  Campaign) 

Ithaca— Schneider,  Franz,  jr.  Survey  of  the  public  health  situation.  Russell  Sage 
Foundation,  Department  of  Surveys  and  Exhibits,  1914.     34p. 

New  York  City — Baker,  S.  J.  Classroom  ventilation  and  respiratory  diseases 
among  school  children.  Reprint  Series  68,  New  York  City  Department  of  Health, 
February  1918.     lOp. 

New  York  City — Neal,  J.  B.  Work  of  the  meningitis  division  of  the  Bureau  Labora- 
tories; illness  census  taken  in  Health  District  no.l.  New  York  City  Department 
of  Health  Bulletin  v.6  no.3,  p67-86  March  1916. 

Onondaga — Sears,  F.  W.  Study  of  sanitary  conditions  on  the  Onondaga  Indian 
Reservation.     Health  News,  Indian  Conference  number  v.14  no.4  April  1919. 

Rochester — Crane,  Mrs.  C.  J.  (B)  Sanitary  survey  of  Rochester,  1911.  Kalama- 
zoo, Michigan.     The  author.     119p. 


1042  Hospital  and  Health  Survey 

Syracuse — Shipley,  A.  E.  Report  on  Syracuse  Board  of  Health.  New  York  Bureau 
of  Municipal  Research,  1912.     12p. 

NORTH  CAROLINA 

Brooker,  W.  H.  Teaching  health  by  motion  pictures.  North  Carolina  State 
Board  of  Health  Bulletin  v.31  no.2  April  1916.  "How  public  health  is  being 
taught  in  rural  districts  by  means  of  traveling  motion  pictures." 

Raleigh — Terry,  C.  E.  Health  survey  of  Raleigh.  Wake  County  of  National  De- 
fense, Child  Welfare  Department,  1918.     29p. 

NORTH  DAKOTA 

Fox,  Carrol  Public  health  administration  in  North  Dakota.  Reprint  315,  U.  S. 
Public  Health  Service,  Public  Health  Reports,  December  1915,  p3658-3688. 

OHIO 

Dayton — Organization  and  administration  of  the  Department  of  Health.  Dayton, 
Bureau  of  Municipal  Research,  1913. 

Piqua — Fox,  Carrol  Public  health  administration  in  Piqua.  U.  S.  Public  Health 
Service,  Public  Health  Reports  v.32  no.25  p974-986.     June  22,  1917. 

Portsmouth — Southmayd,  H.  J.  Health  survey.  Ohio  Public  Health  Journal  v. 8 
p398-411     September  1917. 

Springfield — Fox,  Carrol  Public  health  administration  in  Springfield.  Reprint 
417,  U.  S.  Public  Health  Service,  Public  Health  Reports,  August  10,  1917,  pl255- 
1278. 

Toledo — Fox,  Carrol  Public  health  administration  in  Toledo.  Reprint  284,  U.  S. 
Public  Health  Service,  Public  Health  Reports,  June  25,  1915. 

Youngstown — Fox,  Carrol  Public  health  administration  in  Youngstown.  U.  S. 
Public  Health  Service,  Public  Health  Reports  v.31  no.39  p2653-2685  Septem- 
ber 29,  1916- 

OKLAHOMA 

Norman — Mahr,  J.  C.  and  Ellison,  Gayfree,  comp.  Report  of  the  sanitary  survey 
of  the  town  of  Norman,  made  in  September  1914.     State  Board  of  Health.     37p. 

PENNS  YLVANIA 

Erie — Crane,  Mrs.  C.  J.  (B)  General  sanitary  survey  of  Erie,  1910.  Kalamazoo, 
Michigan.     The  author.     22p. 

Pittsburgh— Report  of  a  survey  of  the  Department  of  Public  Health,  Bureau  of 
Municipal  Research.     Pittsburgh  City  Council  1913.     62p.     (o.p.) 

Reading — Report  on  Department  of  Health.  New  York  Bureau  of  Municipal  Re- 
search.    Reading  Chamber  of  Commerce,  1913.     46p. 


Bibliography  1043 

Uniontown — Crane,  Mrs.  C.  J.  (B)  Sanitary  survey  of  Uniontown.  Women's 
Civic  League,  Uniontown,  1914.     51p. 

RHODE  ISLAND 

Gilbert,  R.  W.  A  study  of  a  typical  mill  village  from  the  standpoint  of  health. 
Rhode  Island  Anti-Tuberculosis  Association  Report,  1910.     15p. 

Pawtucket — Gunn,  S.  M.  Report  on  the  public  health  activities  of  the  city  of 
Pawtucket,     Pawtucket  Business  Men's  Association,  1913.     18p. 

TENNESSEE 

Nashville — Crane,  Mrs.  C.  J.  (B)  General  sanitary  survey  of  Nashville,  1910. 
Kalamazoo,  Michigan.     The  author.     24p. 

TEXAS 

El  Paso — Rich,  J.  P.  and  Arms,  B.  L.  Preliminary  report  of  the  health  survey  of 
El  Paso;  and,  Grossman,  J.  H.  Housing  health  survey.  El  Paso  Chamber  of 
Commerce,  1915.     8p. 

Galveston — Report  of  a  sanitary  survey  of  Galveston.  Galveston  Commercial  Asso- 
ciation, n.d.     30p. 

WASHINGTON 

Crane,  Mrs.  C.  J.  (B)  Report  of  sanitary  conditions  of  cities  of  Washington. 
State  Board  of  Health  Quarterly  Bulletin  v.4  no.l  pl-36.  January,  February, 
March  1914,  incomplete. 

Fox,  Carrol  Public  health  administration  in  the  state  of  Washington.  Reprint 
255,  U.  S.  Public  Health  Service,  Public  Health  Reports,  February  5,  1915.       56p. 

WEST  VIRGINIA 

Clark,  T.  Public  health  administration  in  West  Virginia.  Reprint  252,  U.  S. 
Public  Health  Service,  Public  Health  Reports,  January  22,  1915. 

Charleston — Tolman,  Mayo     Survey  commission  of  sanitary  survey,  1917.    168p. 

WISCONSIN 

Milwaukee — Gunn,  S.  M.  Health  department,  Milwaukee,  Milwaukee  Bureau  of 
Economy  and  Efficiency,  1912.     Bulletins  13,  15,  18. 

Milwaukee — New  York  Bureau  of  Municipal  Research.  April  1913.  131p.  Health 
part  13p. 

ITALY 

Traveling  dispensaries  of  Italy.  The  Public  Health  Nurse.  November  1918. 
p261-262.     Three  illustrations  of  trucks  used  for  dental  and  dispensary  purposes. 

RUSSIA 

Winslow,  C-E.  A.  Public  health  administration  in  Russia  in  1917.  Reprint  445, 
U.  S.  Public  Health  Service,  Public  Health  Reports,  December  28,  1917,  p2191- 
2219. 


1044  Hospital  and  Health  Survey 

MENTAL  HYGIENE  SURVEYS 

GENERAL 

Fernald,  W.  E.  What  is  a  practical  way  for  prevention  of  mental  defect?  Na- 
tional Conference  of  Social  Work.     Proceedings,  1915.     p289-297. 

Fernald,  W.  E.  Standardized  fields  of  inquiry  for  clinical  studies  of  borderline 
defectives'.  National  Committee  for  Mental  Hygiene.  Reprint  8,  24p.  Mental 
Hygiene,  April  1917. 

Wallin,  J.  E.  W.  Scheme  for  the  clinical  study  of  mentally  and  educationally 
unusual  children.  Yale  University  Press,  1914.  20p.  Mental  Health  of  the 
School  Child,  Chapter  19  p429^150. 

UNITED  STATES 

Bowen,  A.  L.  Legislative  provision  for  the  feeble-minded;  what  should  it  be? 
A  study  made  of  the  plans  and  ideas  of  public  and  private  organizations  in  Massa- 
chusetts, New  York  and  Indiana  for  better  provision  for  the  feeble-minded.  Spring- 
field, Illinois,  Public  Charity  Service  of  Illinois,  Institutional  Quarterly  v.7  p66- 
78  December  31,  1916. 

Davenport,  C.  B.  Feebly  inhibited,  violent  temper  and  its  inheritance.  Eu- 
genics Record  Office,  Bulletin  no.12  September  1915.  Reprint,  Journal  of  Nervous 
and  Mental  Disease  v.42  no.9  p593-628     1915. 

ALABAMA 

Haines,  T.  H.     Report,  December  1918.     (not  published) 

ARKANSAS 

Treadway,  W.  L.  Feeble-minded,  their  prevalence  and  needs  in  the  school 
population  of  Arkansas.  Reprint  379,  U.  S.  Public  Health  Service,  Public  Health 
Reports,  November  1916,  p3231-3247. 

CALIFORNIA 

Bridgman,  Olga  Experimental  study  of  abnormal  children  with  special  refer- 
ence to  the  problems  of  dependency  and  delinquency.  Berkeley  University,  Cali- 
fornia.    Publication  in  Psychology  v.3  no.l  March  30,  1918.     59p. 

Terman,  L.  M.,  Williams,  J.  H.,  Fernald,  G.  M.  Surveys  in  mental  deviation  in 
prisons,  public  schools  and  orphanages  in  California;  brief  description  of  local 
conditions  and  need  for  custodial  care  and  training  of  dependent,  defective  and 
delinquent  classes.  California  State  Board  of  Charities  and  Corrections,  1918. 
87p. 

COLORADO 

Hamilton,  S.  W.  Care  and  treatment  of  the  insane  in  Colorado.  Report  to  Na- 
tional Committee  for  Mental  Hygiene,  December  19 16- January  1917.  (not 
published) 

CONNECTICUT 

Wilgus,  S.  D.  Survey  of  Connecticut.  Report  made  to  National  Committee  for 
Mental  Hygiene,     (not  published) 


Bibliography  1045 

DELAWARE 

Richardson,  C.  S.  Dependent,  delinquent  and  defective  children  of  Delaware. 
Russell  Sage  Foundation,  1918.     88p. 

New  Castle  County — Lundberg,  E.  O.  Social  study  of  mental  defectives  in  New 
Castle  County.  U.  S.  Children's  Bureau,  Dependent,  Defective  and  Delinquent 
Classes  Series  no.3  Bureau  Publication  no.24,  1917.     38p. 

New  Castle  Court fv— Mullan,  E.  H.  Mental  status  of  rural  school  children.  Re- 
print 377,  U.  S.  Public  Health  Service,  Public  Health  Reports,  November  1916, 
P3174-3187. 

Sussex  County — Treadway,  W.  L.  and  Lundberg,  E.  O.  Mental  defect  in  a  rural 
county;  a  medico-psychological  and  social  study  of  mentally  defective  children  in 
Sussex  County.  U.  S.  Public  Health  Service  and  U.  S.  Department  of  Labor, 
Children's  Bureau,  Dependent,  Defective  and  Delinquent  Classes  Series  no.7 
Bureau  Publication  no.  48.    96p. 

DISTRICT  OF  COLUMBIA 

Lundberg,  E.  O.  Mental  defectives  in  District  of  Columbia.  U.  S.  Children's 
Bureau  Publication  no.  13,  1915.     39p. 

GEORGIA 

Anderson,  V.  V.  Mental  defectives  in  a  Southern  state  September  1918-Decem- 
ber  1919;  report  of  the  Georgia  Commission  on  feeble-mindedness  and  the  survey 
of  the  National  Committee  for  Mental  Hygiene;  studies  made  mostly  in  institu- 
tions and  schools.  38p  Reprint  from  Mental  Hygiene  v.3  p527-565  October 
1919. 

Hutchings,  R.  H.  Care  and  treatment  of  the  insane  in  Georgia;  report  based  on 
survey  of  the  state  in  September-November  1916  for  National  Committee  for 
Mental  Hygiene,  161  typew.  pages,     (not  published) 

ILLINOIS 

Chicago — Ransom,  J.  E.  Study  of  mentally  defective  children  in  Chicago;  an 
investigation  made  by  the  Juvenile  Protective  Association,  Chicago  Association, 
1915.     72p. 

Cook  County — Adler,  H.  M,  And  the  mentally  handicapped;  a  study  of  the  pro- 
visions for  dealing  with  mental  problems  in  Cook  County.  Report  of  survey 
1916-1917.  National  Committee  for  Mental  Hygiene  Publication  no.13,  1918. 
224p. 

Springfield — Treadway,  W.  L.  Care  of  mental  defectives,  the  insane  and  alcoholics 
in  Springfield.  Russell  Sage  Foundation,  Department  of  Surveys  and  Exhibits, 
1915.     46p.     (Springfield  Survey) 

INDIANA 

Butler,  A.  W.  Mental  Defectives  in  Indiana;  second  report  of  the  Indiana  Com- 
mittee on  mental  defectives  to  the  Governor ;  a  survey  of  8  counties.  Indianapolis, 
1918.     56p. 


1046  Hospital  and  Health  Survey 

Wilgus,  S.  D.  Survey  of  public  care  of  the  mentally  diseased  and  defective  in 
Indiana,  October  1916-December  1917.  National  Committee  for  Mental  Hy- 
giene.    186p.     (not  published) 

Porter  County — Clark,  Taliaferro,  Collins,  G.  L.  and  Treadway,  W.  L.  Mental 
studies  of  rural  school  children  of  Porter  County.  Reprint,  U.  S.  Public  Health 
Service,  Public  Health  Bulletin  no.77  1916.     127p. 

KANSAS 

The  Kallikaks  of  Kansas;  report  of  the  Commission  on  provision  for  the  feeble- 
minded.    Topeka,  1919.     31p. 

KENTUCKY 

Haines,  T.  H.  Report  on  the  condition  of  the  feeble-minded  in  Kentucky  to  the 
State  Commission  on  Provision  for  the  Feeble-minded.     Frankfort,  1916.     23p. 

LOUISIANA 

Haines,  T.  H.     1920.     (under  way) 

MAINE 

Report  of  the  Maine  commission  for  the  feeble-minded  and  of  the  Survey  by  the 
National  Committee  for  Mental  Hygiene.  September  1917-September  1918. 
95p. 

MAR  YLAND 

Anderson,  V.  V.     1920.     (under  way) 

Baltimore — Campbell,  C  M.  Subnormal  child;  a  survey  of  the  school  children  pop- 
ulation in  the  Locust  Point  District  of  Baltimore.  National  Committee  for  Mental 
Hygiene,  Mental  Hygiene  v.l  p96-147  January  1917. 

MASSACHUSETTS 

Community  supervision  of  the  feeble-minded;  an  analysis  of  300  families  in  which 
there  is  mental  defect,  by  welfare  agencies,  members  of  the  League  for  Preventive 
Work.     Boston,  1918.     14p. 

Report  of  the  commission  to  investigate  the  question  of  the  increase  of  criminals, 
mental  defectives  and  degenerates.     Boston,  1911.     50p. 

The  mental  defective  and  the  public  schools  of  Massachusetts;  a  study  of  special 
classes  for  mental  defectives  in  the  public  schools  of  Massachusetts.  League  for 
Preventive  Work,  Publication  no. 2,  1917.     16p. 

MICHIGAN 

Report  of  the  commission  to  investigate  the  extent  of  feeble-mindedness,  epilepsy 
and  insanity,  and  other  conditions  of  mental  defectiveness  in  Michigan.  Lans- 
ing, 1915.     175p. 

MISSISSIPPI 

Haines,  T.  H.  Mississippi  mental  deficiency  survey,  February-May  1920. 
Jackson.     45p. 


Bibliography  1047 

MISSOURI 

Hamilton,  S.  W.  October  1919-April  1920.  (to  be  published  by  State  Board 
of  Charities) 

NEW  JERSEY 

Wilgus,  S.  D.     1920.     (under  way) 

NEW  YORK 

Defective  delinquents;  facts  about  defective  delinquents,  nature,  prevalence, 
institutional  and  legislative  needs  in  the  state  of  New  York.  Memorandum 
submitted  to  the  Hospital  Development  Commission  by  the  New  York  Committee 
on  Feeble-mindedness  and  the  Mental  Hygiene  Committee,  State  Charities  Aid 
Association,  1917.  15p. 

Moore,  Anne  Feeble-minded  in  New  York;  a  report  prepared  for  the  Public 
Education  Association  of  New  York.  New  York  State  Charities  Aid  Association, 
1911.     Hip. 

Nassau  County — Rosanoff,  A.  J.  Survey  of  mental  disorders  in  Nassau  County. 
National  Committee  for  Mental  Hygiene  Publication  no.9  1916.     125p. 

New  York  City — Irwin,  E.  A.  Study  of  the  feeble-minded  in  a  west  side  school  in 
New  York  City.  Public  Education  Association  Bulletin  no.  21  December  8,'  1913. 
15p. 

New  York  City — Kirby,  G.  H.  Classification  and  treatment  of  mental  defectives; 
a  preliminary  report  with  recommendations  to  the  Mayor.  September-October 
1916.     41  typew.  pages. 

New  York  City — Toas,  E.  M.  A  report  of  a  survey  of  the  children  in  the  ungraded 
classes  of  the  Borough  of  the  Bronx.  Ungraded  Teachers'  Association  of  New 
York  City,  "Ungraded"  no.3  p75-82  104-107.     January-February  1918. 

Oneida  County — Carlisle,  C.  L.  Causes  of  dependency ;  based  on  a  survey  of  Oneida 
County.  State  Board  of  Charities,  Division  on  Mental  Defect  and  Delinquency, 
1918.     Eugenics  and  Social  Welfare  Bulletin,  no. 15.     465p. 

NORTH  CAROLINA 

MacDonald,  S.  D.     February-May  1920.     (under  way) 

OHIO 

Sessions,  M.  A.  Feeble-minded  in  a  rural  county  of  Ohio.  Bureau  of  Juvenile 
Research,  Bulletin  no.6,  Publication  no.12  February  1918.     69p. 

PENNS  YLVANIA 

Finlayson,  A.  W.  Dack  family;  a  study  in  hereditary  lack  of  emotional  control. 
Eugenics  Record  Office  Bulletin  no.15  May  1916.     46p. 

Haviland,  C.  F.  Treatment  and  care  of  the  insane  in  Pennsylvania.  Philadel- 
phia Public  Charities  Association,  1915.     94p. 


1048  Hospital  and  Health  Survey 

Key,    W.    E.     Feeble-minded    citizens    in    Pennsylvania.      Philadelphia    Public 
Charities  Association,  1915.     63p. 

Philadelphia — Three  pamphlets:  1 — Fate  of  the  friendless  feeble-minded  women, 
8p;  2 — Number  of  the  feeble-minded,  13p;  3 — Public  provision  for  the  feeble- 
minded, a  symposium,  16p.  Philadelphia  Department  of  Health  and  Charities. 
J.  S.  Neff,  Director. 

Philadelphia— Salmon,  T.  W.     June  1920.     (under  way) 

Scranton — Salmon,  T.  W.  Treatment  of  the  insane  in  the  Scranton  poor  district. 
1916. 

SOUTH  CAROLINA 

Report  on  the  State  Hospital  for  the  Insane  at  Columbia.      January  1915.     A.  P. 
Herring,  investigator.     20p. 

Columbia — Report  sent  to  Hon.  Richard  I.  Manning,  Governor  of  South  Carolina, 
on  the  State  Hospital  for  the  Insane  at  Columbia,  with  recommendations  by  A.  P. 
Herring,  1915.     20p. 

TENNESSEE 

Haines,  T.  H.     Department  of  State  Charities  and  Tennessee  Society  for  Mental 
Hygiene,  January-April  1919. 

Wilgus,   S.    D.     Report   to   National    Committee   for   Mental   Hygiene,    October- 
December  1915.     (330  typew.  pages,  not  published) 

TEXAS 

Salmon,  T.  W.     Most  urgent  needs  of  the  insane  in  Texas;  an   address,    February 
1916. 

Grayson  County — Salmon,  T.  W.  Insane  in  a  country  poor  farm.  National  Com- 
mittee for  Mental  Hygiene.  9p.  Reprint,  Mental  Hygiene  v.l  no.l  p25-33.  Jan- 
uary 1917. 

WISCONSIN 

Anderson,  V.  V.     1920.     (under  way) 

Hart,  H.  H.     Wisconsin   system    of  county   asylums  for  the  insane  proposed  for 
adoption   in  Oklahoma;  a  special  report.     Racine.     The  author.     1908.     12p. 

Haviland,  C.  F.     County  care.     September-October  1913. 

Gillen,  J.  L.     Some  aspects    of    feeble-mindedness  in  Wisconsin.     University  of 
Wisconsin  Bulletin  Serial  no.940,  General  Series  no.727,  June  1918.     30p. 

CANADA 

)ntario— MacMurchy,  Helen     The  feeble-minded  in  Ontario.     Toronto,  1913.  52p. 


Bibliography  1049 

INFANT  MORTALITY  AND  CHILD  WELFARE  SURVEYS 

GENERAL 

Meigs,  G.  L.  Infant  welfare  in  wartime.  American  Medical  Association.  Re- 
print from  the  American  Journal  of  Diseases  of  Children  v.14  p80-97  August. 
1917. 

UNITED  STATES 

Baby-saving  campaigns;  a  preliminary  report  on  what  American  cities  are  doing 
to  prevent  infant  mortality,  1913.  U.  S.  Department  of  Labor,  Children's  Bureau, 
Infant  Mortality  Series  no.l,  Bureau  Publication  no.3.     93p. 

Infant  mortality  and  its  relation  to  the  employment  of  mothers,  prepared  under 
the  direction  of  C.  P.  Neill  v.13  174p.  Report  on  condition  of  women  and  child 
workers  in  the  United  States,  U.  S.  Senate  61st  Congress  Second  Session,  Docu- 
ment 645.     19  vols. 

Infant  mortality  and  milk  stations;  special  report  dealing  with  the  problem  of  re- 
ducing infant  mortality;  work  carried  on  in  ten  cities  in  the  United  States  together 
with  details  of  administration  of  public  and  private  agencies  in  New  York  State 
during  1911  to  determine  the  value  of  milk  station  work  as  a  direct  means  of  re- 
ducing infant  mortality.     New  York  City,  Milk  Committee,  1912.     176p. 

Hibbs,  H.  H.  jr.  Infant  mortality;  its  relation  to  social  and  industrial  conditions. 
Russell  Sage  Foundation,  1916.     127p. 

Phelps,  E.  B.  Statistical  survey  of  infant  mortality's  urgent  call  for  action. 
American  Statistical  Association,  Quarterly  Publication,  v.12  no.92  p341-359  De- 
cember 1910. 

Van  Ingen,  Philip  Recent  progress  in  infant  welfare  work.  American  Medical 
Association,  1914.  23p.  Reprint  from  the  American  Journal  of  Diseases  of 
Children  v.7  p471^93     June  1914. 

ALABAMA 

Child  welfare  in  Alabama;  an  inquiry  by  the  National  Child  Labor  Committee 
under  the  auspices  and  with  the  cooperation  of  the  University  of  Alabama,  E.  N. 
Clopper,  director.     New  York  City.     The  committee.     1918.     249p. 

CONNECTICUT 

Waterbury — Hunter,  E.  B.  Infant  mortality;  results  of  field  study  in  Waterbury, 
based  on  births.  U.  S.  Department  of  Labor,  Children's  Bureau,  Infant  Mor- 
tality Series  no.7,  Bureau  Publication  no.29     157p. 

ILLINOIS 

Chicago — Guild,  A.  A.  Baby  farms  in  Chicago;  an  investigation  made  for  the  Ju- 
venile Protective  Association.     Chicago.     The  association.     1917.     p27-34. 

Chicago — Kingsley,  S.  C.  Steps  in  the  evaluation  of  baby  welfare  work  in  Chicago. 
Elizabeth  McCormick  Memorial  Fund,  1914      32p. 


1050  Hospital  and  Health  Survey 


Springfield — Geister,  Janet  The  child  welfare  special;  description  of  child  welfare 
special  of  Children's  Bureau  and  its  tour.  Springfield,  Institution  Quarterly, 
December  31,  1919.     pl20-125. 

KANSAS 

Moore,  Elizabeth  Maternity  and  infant  care  in  a  rural  county  in  Kansas. 
U.S.  Children's  Bureau,  Rural  Child  Welfare  Series,  no.l,  Bureau  Publication  no. 
26,  1917.     50p. 

KENTUCKY 

Slingerland,  W.  H.  Child  welfare  work  in  Louisville;  a  study  of  conditions, 
agents  and  institutions.     Louisville  Welfare  League,  1919.     152p. 

LOUISIANA 

New  Orleans  and  Louisiana — Slingerland,  W.  H.  Constructive  program  of  organ- 
ized child  welfare. work  for  New  Orleans  and  Louisiana.  An  address  delivered 
before  the  Social  Workers'  Section  Southern  Sociological  Congress  at  New  Orleans, 
April  1916.  Russell  Sage  Foundation,  1916.  Reprint  from  proceedings  of  the 
Congress  for  the  Department  of  Child  Helping,  Russell  Sage  Foundation,  July 
1915.     36p. 

MASSACHUSETTS 

Phelps,  E.  B.  Infant  mortality  and  its  relation  to  women's  employment;  a 
study  of  Massachusetts  statistics.  Women  and  Child  Wage  Earners  in  the  United 
States  v.12  part  1  pl-121     1911. 

Safford,  M.  V.  Influence  of  occupation  on  health  during  adolescence.  U.  S. 
Public  Health.Service,  Public  Health  Bulletin  no.78,  August  1916.     51p. 

Brockton — Dempsey,  M.  V.  Infant  mortality;  results  of  a  field  study  in  Brockton, 
based  on  births  in  one  year.  U.  S.  Department  of  Labor,  Children's  Bureau,  In- 
fant Mortality  Series  no.  6,  Bureau  Publication  no.  37,  1919.     82p. 

Fall  River — Dublin,  L.  I.  Infant  mortality  in  Fall  River;  a  survey  of  the  mortality 
among  833  infants  born  in  June,  July  and  August  1913.  American  Statistical 
Association,  Quarterly  Publication  v.14  p505-520     June  1915. 

Fall  River — Keisker,  L.  M.  Infant  mortality  and  its  relation  to  the  employment  of 
mothers  in  Fall  River.  Women  and  Child  Wage  Earners  in  the  United  States 
v.12  part  2  p75-174     1911. 

MONTANA 

Paradise,  V.  I.  Maternity  care  and  the  welfare  of  young  children  in  a  home- 
steading  county  in  Montana.  U.  S.  Department  of  Labor,  Children's  Bureau, 
Rural  Child  Welfare  Series  no.3,  Bureau  Publication  no.34,  1919.     98p. 

NEW  HAMPSHIRE 

Young,  A.  A.  Birth  rate  in  New  Hampshire.  American  Statistical  Association, 
Quarterly  Publication  v.9  p263-281     September  1905. 


Bibliography  1051 

NEW  JERSEY 

Essex  County — Infant  mortality  report  of  the  Public  Welfare  Committee  of  Essex 
County.     Newark.     The  committee.      1912.     32p. 

Montclair — Infant  mortality;  a  study  of  infant  mortality  in  a  suburban  community. 
U.  S.  Department  of  Labor,  Children's  Bureau,  Infant  Mortality  Series  no.  4, 
Bureau  Publication  no. 11,  1915.     36p. 

NEW   YORK 

New  York  City — Boarded-out  babies,  L.  D.  Wald,  director.  The  Association  of 
Neighborhood  Workers  of  the  City  of  New  York,  n.  d.     7p. 

New  York  City — Infant  mortality  and  the  milk  situation;  special  report  of  the  Com- 
mittee for  the  reduction  of  infant  mortality  of  the  New  York  Milk  Committee,  New 
York  City  Milk  Committee,  1912.      176p. 

Ogdensburg — Wakeman,  B.  R.  Survey  of  the  infant  mortality  and  stillbirths  of 
the  city  of  Ogdensburg,  for  the  year  1915.  36th  Annual  Report  of  the  New  York 
State  Department  of  Health  v.3  p44-73     1915. 

NORTH  CAROLINA 

Bradley,  F.  S.  and  Williamson,  Margaretta  Rural  children  in  selected  coun- 
ties of  North  Carolina.  U.  S.  Department  of  Labor,  Children's  Bureau,  Rural 
Child  Welfare  Series  no.2,  Bureau  Publication  no.33,  1918.     118p. 

Child  welfare  in  North  Carolina;  an  inquiry  by  the  National  Child  Labor  Com- 
mittee for  the  North  Carolina  conference  for  social  service.  W.  H  Swift,  director. 
New  York  City.     The  committee.      1918.     314p. 

OKLAHOMA 

Child  welfare  in  Oklahoma;  an  inquiry  by  the  National  Child  Labor  Committee 
for  the  University  of  Oklahoma.  E.  N.  Clopper,  director.  New  York  City.  The 
committee.     1917.     285p. 

OREGON 

Slingerland,  W.  H.  Child  welfare  work  in  Oregon;  a  study  of  public  and  private 
agencies  and  institutions  for  the  care  of  dependent  delinquents  and  defective  chil- 
dren for  the  Oregon  Child  Welfare  Commission.  University  of  Oregon  Extension 
Division  Bulletin,  July  1918.     131p. 

PENNS  YLVANIA 

Child  welfare  symposium;  25  special  papers  contributed  by  leading  Pennsylvanians, 
supplement  to  Child  Welfare  Work  in  Pennsylvania.  Russell  Sage  Foundation, 
1915.     138p. 

Hart,  H.  H.  Summary  of  child  welfare  work  in  Pennsylvania.  Russell  Sage 
Foundation,  1915.     34p. 

Slingerland,  W.  H.  Child  welfare  work  in  Pennsylvania;  a  cooperative  study  of 
child  helping  agencies  and  institutions.     Russell  Sage  Foundation,  1915.     352p. 


1052  Hospital  and  Health  Survey 

RHODE  ISLAND 

Aronovici,  Carrol  Some  nativity  and  race  factors  in  Rhode  Island.  Provi- 
dence, 1910.  Reprint  from  Annual  Report  of  the  Commission  of  Industrial  Sta- 
tistics of  Rhode  Island,  1909.     p2 19-423. 

WISCONSIN 

Brown,  F .  ,B-  and  Moore,  Elizabeth  Maternity  and  infant  care  in  two  rural 
counties  in  Wisconsin.  U.  S.  Children's  Bureau,  Rural  Child  Welfare  Series  no. 
4,  Bureau  Publication  no.46,  1919.     92p. 

CANADA 

Ottawa — Traveling  baby  clinic;  Ottawa  trucks  used  as  clinics.  Conservation  of 
Life,  July  1919.     p60-62. 

ENGLAND 

Unwin,  T.  F.  Second  report  on  infant  and  child  mortality  in  London.  42nd 
Annual  Report  of  the  Local  Government  Board,  1912-1913.  411p.  Supplement 
in  continuation  of  the  report  of  the  medical  officer  of  the  board  for  1912-1913. 

SOCIAL  SURVEYS 

UNITED  STATES 

Taylor,  G.  R.     Satellite  cities.     New  York,  Appleton,  1915.     333p. 

ALABAMA 

Birmingham — Kellogg,  P.  U.,  Harrison,  S.  M.  and  others.  Smelting  iron  ore  and 
civics.     Survey  v.27  pl451-1556     January  6,  1913. 

CALIFORNIA 

Los  Angeles — Bartlett,  D.  W.  Better  city;  a  sociological  study  of  a  modern  city. 
Los  Angeles,  1907.     248p. 

San  Diego — King,  E.  S.  and  F.  A.  Pathfinder  social  survey  of  San  Diego.  San 
Diego  College  Women's  Club,  1914.     48p. 

CONNECTICUT 

Bridgeport — Report  on  welfare  work  in  Bridgeport  and  elsewhere.  Committee  of 
Manufacturers'  Association,  1918. 

New  Haven — Documents  of  the  civic  federation.  15  pamphlets.  The  Federation, 
1909-1915. 

ILLINOIS 

Chicago — Reports  of  the  Bureau  of  Social  Surveys.  Chicago  Department  of  Public 
Welfare,  semi-annual  report,  1914-1915.  , 

Springfield — Springfield  survey.  S.  M.  Harrison,  director.  10  pamphlets.  Russell 
Sage  Foundation,  Department  of  Surveys  and  Exhibits,  1915.  Treadway,  W.  L. 
Care  of  mental  defectives,  the  insane  and  alcoholics.  46p.  Schneider,  Franz, 
jr.,  Public  health.     159p. 


Bibliography  1053 


KANSAS 

Belleville — Burgess,  E.  W.  and  Sippy,  J.  J.     Belleville  social    survey.     University  of 
Kansas,  n.  d.     70p. 

Lawrence — Blackmar,  F.  W.  and  Burgess,  E.  W.     Social  survey  of  Lawrence,  1917. 
122p. 

Minneapolis — Elmer,  M.  C.     Survey  by,  1918.     39p. 

Topeka — Topeka   improvement   survey.     S.   M.   Harrison,    director.      4   pamphlets. 
Russell  Sage  Foundation,  Department  of  Surveys  and  Exhibits,  1914.     Schneider, 
•     Franz,  jr.,  3rd  part — Public  health. 

MASS  A  CHU SETTS 

Lawrence — Todd,  R.  E.  and  Sanborn,  F.  B.  Report  of  the  Lawrence  survey.  Trus- 
tees of  the  White  Fund,  1912.     262p.     Covers  milk  supply  and  housing. 

Lou;eZZ— Kengott,  George     Record  of  a  city.     New   York,  Macmillan,      1912      257p. 

MISSOURI 

Kansas  City — Reports  of  public  welfare  board.     1913.     104p. 

Springfield — Springfield  social  survey,  W.  T.  Cross,  director,  R.  H.  Leavell,  field 
worker.     Springfield  Social  Survey  Council  n.  d.  33p. 

NEW  JERSEY 

Montclair — Burns,  A.  T.  Need  and  scope  of  a  social  survey.  Montclair.  Survey 
committee,  1912.     23p. 

NEW  YORK 

Albany — Hun,  M.V.     Some  facts  about  Albany.     Albany.     The  author.     1912.  30p. 

Buffalo — Daniels,  John  Americanizing  80,000  Poles.  Survey  v.24  p373-385  June 
4,  1910. 

Newburgh — Newburgh  survey.  Z.  L.  Potter,  director  of  field  work.  Russell  Sage 
Foundation,  Department  of  Surveys  and  Exhibits,  1913.     104p. 

NORTH  DAKOTA 

Fargo — Social  survey  of  Fargo,  by  Social  Science  Department,  Fargo  College,  under 
M.  C.  Elmer.     Fargo  Associated  Charities,  1915.     46p. 

PENNS  YLVANIA 

Coopersburg — Morrison,  T.  M.  Coopersburg  survey.  Easton,  Moravian  Country 
Church  Association,  1915.     34p. 

Pittsburgh — Holdsworth,  J.  T.  Economic  survey  of  Pittsburgh.  Pittsburgh.  The 
author.     1912.     229p. 

Pittsburgh — Kellogg,  P.  U.,  editor  Pittsburgh  survey.  New  York  Charities  Pub- 
lishing Committee,  1909-1914.  6  vols.  Russell  Sage  Foundation  publication  6 
parts. 


1054  Hospital  and  Health  Survey 

Reading — Report  on  a  survey  of  the  municipal  departments  and  the  school  dis- 
trict. New  York  Bureau  of  Municipal  Research,  8  pamphlets.  Reading  Chamber 
of  Commerce,  1913.     1 — Department  of  Health.     46p. 

Scranton — Harrison,  S.  M.  and  others.  Scranton  in  quick  review.  Scranton  Cen- 
tury Club,  1913.     31p. 

RHODE  ISLAND 

Newport — Aronovici,  Carrol  Newport  survey  of  social  problems,  Newport  Sur- 
vey Committee,  1911.     59p. 

Providence — Kirk,  William  Modern  city.  University  of  Chicago  Press,  1909. 
363p. 

TEXAS 

Austin — Hamilton,  B.  Social  survey  of  Austin.  1913.  Bulletin  University  of  Texas, 
Humanistic  Series  no.  15. 

Austin — Terry,  C.  E.  and  Schneider,  Franz,  jr.  Social  survey  of  the  city  of  Austin. 
40p.     (Delineator  7th  Baby  Campaign,  1917.) 

WISCONSIN 

Milwaukee — Bureau  of  Economy  and  Efficiency.     Bulletins  1-19.     1911-1912.  (o.  p.) 

CANADA 

London — Riddell,  W.  A.  and  Myers,  A.  J.  W.  Survey.  Toronto  Board  of  Social 
Service  and  Evangelism,  Presbyterian  Church,  1913.     99p. 

Regina — Woodsworth,  J.  S.  Report  of  a  preliminary  and  general  social  survey  of 
Regina.     Toronto  Board  of  Social  Service  and  Evangelism,  1913.     48p. 

Sydney — Stewart,  B.  M.  Preliminary  and  general  social  survey  of  Sydney.  To- 
ronto Board  of  Social  Service  and  Evangelism,  Presbyterian  Church,  1913.     29p. 

INDUSTRIAL  HYGIENE  SURVEYS 

UNITED  STATES 

Danger  to  workers  from  dusts  and  fumes,  and  methods  of  precaution.  U.  S. 
Department  of  Labor,  Bureau  of  Labor  Statistics,  Bulletin  Industrial  Accidents  and 
Hygiene  Series  no. 3  whole  no. 127  August  12,  1913.     22p. 

Eye  hazards  in  industrial  occupations;  a  report  of  typical  cases  and  conditions 
with  recommendations  for  safe  practice.  National  Committee  for  Prevention  of 
Blindness  no.12,  1917.      145p. 

Hygiene  of  the  painters'  trade.  U.  S.  Department  of  Labor,  Bureau  of  Labor 
Statistics,  Bulletin  Industrial  Conditions  and  Hygiene  Series  no. 2,  whole  no. 120 
May  13,  1913.     68p. 

Lead  poisoning  in  the  manufacture  of  storage  batteries.  U.  S.  Department  of 
Labor,  Bureau  of  Labor  Statistics,  Bulletin  Industrial  Accidents  and  Hygiene 
Series  no. 6  whole  no. 165     December  15,  1914.     38p. 


Bibliography  1055 

Lead  poisoning  in  potteries,  tile  works  and  porcelain  enamelled  sanitary  ware 
factories.  U.  S.  Department  Commerce  and  Labor,  Bureau  of  Labor  Statistics, 
Bulletin  Industrial  Accidents  and  Hygiene  Series  no.l  whole  no.  104  August  ,7, 
1912.     95p. 

Lead  poisoning  in  the  smelting  and  refining  of  lead.  U.  S.  Department  of  Labor, 
Bureau  of  Labor  Statistics,  Bulletin  Industrial  Accidents  and  Hygiene  Series  no.  4 
whole  no.141     February  17,  1914.     97p. 

Schroeder,  M.  C.  and  Southerland,  S.  G.  Laundries  and  the  public  health.  U.  S. 
Public  Health  Service,  Public  Health  Reports  v.32  p2 2 5-246     February  9,  1917. 

Boston,  New  York  City,  Philadelphia,  Baltimore,  Washington,  Chicago,  St. 
Louis — Hamilton,  Alice  and  Verrill,  C.  H.  Hygiene  of  the  printing  trades.  U.  S. 
Department  of  Labor,  Bureau  of  Labor  Statistics  Bulletin  Industrial  Accidents 
and  Hygiene  Series  no.  12  whole  no.  2  09.     118p. 

Orange  Valley,  Newark,  Danbury,  Philadelphia,  Fall  River — Sanitary  standards 
for  the  felt  hatting  industry.     Trenton.     The  state.     1915 

INDIANA 

White,  M.  J.  Sanitary  survey  of  Indiana  industries  employing  women  labor. 
U.S.  Public  Health  Service,  Supplement  17  to  Public  Health  Reports,  July  17,  1914. 
44p. 

MASSACHUSETTS 

Hygiene  of  the  boot  and  shoe  industry  in  Massachusetts.  Boston.  The  state. 
1912.     31p.     7  plates. 

Report  of  the  State  Board  of  Health  upon  the  sanitary  condition  of  factories, 
workshops  and  other  establishments  where  persons  are  employed.  Boston. 
The  state.     1907.     144p. 

NEW  YORK 

New  York  City — Goldmark,  Pauline.  Notes  on  an  industrial  survey  of  a  selected 
area  in  New  York  City,  with  respect  to  sanitary  conditions  in  the  factories. 
1917.  Reprint  of  appendix  5  to  preliminary  report  of  the  New  York  State 
Factory  Investigating  Commission.  Submitted  to  Legislature  March  1,  1912. 
p297-363. 

New  York  City — Guilfoy,  W.  H.  and  Wynne,  S.  W.  Illness  census  taken  in  Health 
District  no.l.  New  York  City  Department  of  Health  Bulletin  v. 6  no.2  p71-80 
March  1916. 

New  York  City — Harris,  L.  I.  Clinical  and  sanitary  study  of  the  fur  and  hatters 
fur  trade.  New  York  City  Department  of  Health  Bulletin  v.5  no.10  p267-298. 
October  1915. 

New  York  City — Harris,  L.  I.  Clinical  study  of  the  frequency  of  lead,  turpentine 
and  benzine  poisoning  in  400  painters.  New  York  City  Department  of  Health 
reprint,  surveys  no. 65,  August  1918. 


1056  Hospital  and  Health  Survey 

New  York  City — Harris,  L.  I.  Health  of  workers  in  garages;  a  preliminary  study. 
New  York  City  Department  of  Health  Bulletin  v.8  no.ll.     November  1918. 

New  York  City — Harris,  L.  I.  and  Swartz,  Nelle  Cost  of  clean  clothes  in  terms 
of  health;  a  study  of  laundries  and  laundry  workers  in  New  York  City,  1916.     96p. 

New  York  City — McMillan,  M.  B.  Sanitary  survey  of  a  "Trial"  city  block.  New 
York  City  Department  of  Health  Bulletin  v.6  no.8  p215-220.     August  1916. 

New  York  City — Pratt,  E.  E.  Occupational  diseases;  a  preliminary  report  on  lead 
poisoning  in  the  City  of  New  York  with  an  appendix  on  arsenical  poisoning.  1912. 
Reprint  of  appendix  6  to  preliminary  report  of  the  New  York  State  Factory  Investi- 
gating Commission.     Submitted  to  Legislature  March  1,  1912.     p365-596. 

New  York  City — Price,  G.  M.  General  survey  of  the  sanitary  conditions  of  the 
shops  in  the  cloak  industry.  Reprint  from  1st  Annual  Report  of  the  Joint  Board 
of  Sanitary  Control  in  the  cloak,  suit  and  skirt  industry  of  Greater  New  York, 
1911.     40p. 

New  York  City — Price,  G.  M.  Special  report  on  sanitary  conditions  in  the  shops 
of  the  dress  and  waist  industry;  a  preliminary  report  made  by  the  Joint  Board 
of  Sanitary  Control  in  the  dress  and  waist  industry,  1913.     23p. 

New  York  City — Report  on  the  sanitation  of  bakeries  in  New  York  City.  New 
York  Commissioner  of  Sanitation  of  Bakeries,  1911.     16p. 

New  York  City — Schereschewsky,  J.  W.  Health  of  garment  workers.  U.  S.  Pub- 
lic Health  Service,  Public  Health  Reports  v.31  no.21  pl298-1305  May  26, 
1916. 

New  York  City — Schroeder,  M.  C.  and  Southerland,  S.  C.  Laundries  and  the  public 
health.  U.  S.  Public  Health  Service,  Public  Health  Reports  v.32  no.6  p225-246 
February  9,  1917. 

New  York  City — Studies  in  vocational  disease:  Schereschewsky,  J.  W.,  Health  of 
garment  workers;  and,  Schereschewsky,  J.  W.  and  Tuck,  D.  H.,  Hygienic  con- 
ditions of  illumination  in  workshops  of  the  women's  garment  industry.  U.  S. 
Public  Health  Service  Bulletin  no.71,  1915. 

New  York  City — Wynne,  S.  W.  Second  illness  census  in  the  experimental  health 
district.  New  York  City  Department  of  Health  Bulletin  v.6  no.ll  p289-314 
November   1916. 

OHIO 

Hayhurst,  E.  R.  Industrial  health  hazards  and  occupational  diseases  in  Ohio. 
Columbus  State  Board  of  Health,  1915.     438p. 

GREAT  BRITAIN 

Hours,  fatigue  and  health  in  British  munition  factories.  U.  S.  Department  of 
Labor,  Bureau  of  Labor  Statistics  Bulletin  Industrial  Accident  and  Hygiene  Series 
no.15  whole  no.221     April  1917.     147p. 


Bibliography  1057 

TUBERCULOSIS  SURVEYS 

GENERAL 

Homan,  J.     Instruction  of  the  public   in   anti-tuberculosis   measures  by  a  traveling 

exhibit.     Journal   American  Medical  Association  v.55  pl072-1073.     September  24, 

1910. 

i 

Ransome,  Arthur     International   researches   in    tuberculosis.     The   Weber-Parkes 

Prize  Essay,  1897.     London,  England,  1898.     84p. 

ALASKA 

Michel,  H.  C.  Tuberculosis  survey  of  an  Alaskan  Eskimo  village,  using  children 
under  the  age  of  15  years  as  an  index.  Reprint  90,  Medical  Record,  October  14, 
1916,  p663-666.     Wm.  Wood  &  Co. 

GEORGIA 

Anti-tuberculosis  activities  in  Georgia.  Atlanta  Raoul  Foundation,  1916.  Folder 
no.3 .     (unpublished) 

ILLINOIS 

Chicago — O'Neill,  E.  J.  School  survey  as  observed  at  Stock  Yards  dispensary. 
Municipal  Tuberculosis  Sanitarium  Monthly,  Bulletin  no.l  pl3-15     March    1918. 

Chicago — Robertson,  J.  D.  Tuberculosis  problem  in  the  city  of  Chicago.  Reprint, 
American  Journal  of  Public  Health,  April  1918.     lip. 

INDIANA 

Richmond — Perry,  J.  C.  Report  of  a  survey  to  determine  an  incident  of  tubercu- 
losis. U.  S.  Public  Health  Service,  Supplement  26  to  Public  Health  Reports, 
October  8,  1915.     62p. 

MASSACHUSETTS 

Barnstable  County — Billings,  B.  W.  Tuberculosis  survey.  Boston  State  Depart- 
ment, Health  in  Commonwealth  v.5  p207-210     August  1918. 

Boston — Locke,  E.  A.  and  Floyd,  Cleaveland  Economic  study  of  500  consump- 
tives treated  in  the  Boston  Consumptive  Hospital,  1911.  Reprint,  Transactions 
of  the  New  York  Association  for  the  Study  and  Prevention  of  Tuberculosis.     9p. 

Framingham — Armstrong,  D.  B.  Community  health  and  tuberculosis  demon- 
stration; a  series  of  pamphlets  Monograph  1 — The  program,  Medical  series  1 — The 
sickness  census,  2 — Medical  examination  campaign,  3 — Tuberculosis  findings. 
1917-1918. 

MICHIGAN 

Report  of  the  tuberculosis  survey  of  the  State  Board  of  Health  for  the  12  months 
from  October  1915  to  October  1916.     Lansing.     The  state,  1917.     89p. 

MINNESOTA 

Minneapolis — Lampson,  H.  L.  Study  of  the  spread  of  tuberculosis  in  families. 
University  of  Minnesota  studies  in  Public  Health  Bulletin  no.l,  December  1913. 
50p. 


1058  Hospital  and  Health  Survey 

MISSOURI 

Joplin — Lanza,  A.  J.  and  Higgins,  Edwin  Pulmonary  disease  among  miners  in 
the  Joplin  district  and  its  relation  to  rock  dust  in  the  mines;  a  preliminary  re- 
port. Department  of  Interior,  Bureau  of  Mines,  Educational  paper  105,  1915. 
47p. 

NEW  JERSEY 

Tuberculosis  survey  of  New  Jersey  and  report.  Newark,  New  Jersey,  Anti- 
Tuberculosis  League,  1917.     48p. 

NEW  YORK 

Amsterdam — Brown,  U.  D.  Houses  of  Amsterdam  with  some  notes  on  the  prev- 
alence of  tuberculosis.     State    Charities  Aid  Association,  1917.     61p. 

Clinton  County — Smith,  J.  A.  A  tuberculosis  survey  of  Clinton  County.  New 
York  State  Department  of  Health,  Health  News,  March  1919,  p56-62. 

New  York  City — Dispensary  control  of  tuberculosis  in  New  York  City.  11th  Annual 
Report  of  the  Association  of  Tuberculosis  Clinics  of  the  City  of  New  York,  1918. 
35p. 

Saranac  Lake — Ames,  F.  B.  A  tuberculosis  survey  of  the  residents  of  Saranac 
Lake.  National  Tuberculosis  Journal,  American  Review  of  Tuberculosis  v.2  no.4 
p207-236  June  1918. 

OHIO 

Survey  of  the  tuberculosis  situation  in  the  state  of  Ohio;  prepared  by  the  Ohio 
State  Society  for  the  Prevention  of  Tuberculosis.  State  Board  of  Health,  1912. 
49p. 

Cincinnati — Nelson,  N.  A.  Study  of  tuberculosis  mortality,  1910-1917,  with 
special  reference  to  the  Negro.  Anti-Tuberculosis  League  allied  drive  for  Public 
Health,  pl8-29. 

Cincinnati — Robinson,  D.  E.  and  Wilson,  J.  G.  Tuberculosis  among  industrial 
workers.     U.  S.  Public  Health  Service,  Public  Health  Bulletin  no.  73,   1916.    143p. 

PENNS  YLVANIA 

Pittsburgh — Steward,  A.  E.  and  Simmonds,  V.  S.  Tuberculosis  League;  first  sur- 
vey report  of  Dispensary  Aid  Society  on  tuberculosis  and  infant  welfare;  a  study 
of  8  city  squares,  1916.     65p. 

RHODE  ISLAND 

Gilbert,  R.  W.  A  study  of  a  typical  mill  village  from  the  standpoint  of  health. 
Rhode  Island  Anti-Tuberculosis  Association  report,  1910.     15p. 

VERMONT 

New  features  in  the  anti-tuberculosis  campaign.  Vermont  State  Board  of 
Health  Bulletin  v.13  no.3  p71-75  March  1,  1913. 


Bibliography  1059 


GERMANY 

Care  of  tuberculosis  wage  earners  in  Germany.  U.  S.  Department  of  Commerce 
and  Labor,  Bureau  of  Labor  Bulletin  Workman's  Insurance  and  Compensation 
Series  no.l,  whole  no.101     July  1912.     183p. 

SICKNESS  SURVEYS 

MASSACHUSETTS 

Boston — Frankel,  L.  K.  and  Dublin,  L.  I.  Sickness  survey  of  Boston.  New  York 
City,  Metropolitan  Life  Insurance  Co.,  1916.     23p. 

MISSOURI 

Kansas  City — Frankel,  L.  K.  and  Dublin,  L.  I.  Health  census  of  Kansas  City. 
New  York  City,  Metropolitan  Life  Insurance  Co.,  1917.     Up. 

NEW  YORK 

Dutchess  County — A  sickness  survey  in  Dutchess  County.  New  York,  State  Chari- 
ties Aid  Association,  Publication  no.136,  1915.     102p. 

Dutchess  County — Weber,  J.  J.  A  county  at  work  on  its  health  problems;  a 
statement  of  accomplishment  by  the  Dutchess  County  Health  Association  during 
the  16  months  from  August  1916  to  December  1917,  inclusive.  New  York, 
State  Charities  Aid  Association.     27p. 

New  York  City — Health  census  of  Chelsea  neighborhood  by  Metropolitan  Life 
Insurance  Company  and  Chelsea  Neighborhood  Association.  New  York  City, 
Metropolitan  Life  Insurance  Co.,  1917.     16p. 

Rochester — Frankel,  L.  K.  and  Dublin,  L.  I.  Community  sickness  survey.  New 
York  City,  Metropolitan  Life  Insurance  Co.,     1917.     22p. 

NORTH  CAROLINA 

Frankel,  L.  K.,  and  Dublin,  L.  I.  Sickness  survey  of  North  Carolina.  U.  S.  Public 
Health  Service,  Public  Health  Reports  v.31  no.41  p2820-2844     October  1916. 

OHIO 

O'Grady,  John  Public  care  of  sick  and  diseased;  a  survey  of  hospital  care  in 
Ohio  infirmaries.  Board  of  State  Charities,  Ohio  Bulletin  of  Charities  and  Cor- 
rection v.24  no.4     December  1918.     19p. 

PENNSYLVANIA  AND  WEST  VIRGINIA 

Frankel,  L.  K.  and  Dublin,  L.  I.  Sickness  survey  of  the  principal  cities  in  Penn- 
sylvania and  West  Virginia.  New  York  City,  Metropolitan  Life  Insurance  Co., 
1917.     78p. 

PENNSYLVANIA 

Pittsburgh — Frankel,  L.  K.  and  Dublin,  L.  I.  Sickness  survey  of  Pittsburgh. 
New  York  City,  Metropolitan  Life  Insurance  Co.,  1917.     22p. 


1060  Hospital  and  Health  Survey 

SOUTH  CAROLINA 

Sydenstricker,  Edgar,  Wheeler,  G.  A.  and  Goldberger,  Joseph  Disabling  sick- 
ness among  the  population  of  seven  cotton  mill  villages  of  South  Carolina,  in  re- 
lation to  family  income.  U.  S.  Public  Health  •  Service,  Public  Health  Reports, 
v.33  no.47.     November  22,  1918.     14p. 

WEST  VIRGINIA 

Frankel,  L'.  K.  and  Dublin,  L.  I.  Sickness  survey  of  West  Virginia  cities.  New 
York  City,  Metropolitan  Life  Insurance  Co.,  1917.     lip. 

WEST  VIRGINIA  AND  PENNSYLVANIA 

Frankel,  L.  K.  and  Dublin,  L.  I.  Sickness  survey  of  the  principal  cities  in  Penn- 
sylvania and  West  Virginia.  New  York  City,  Metropolitan  Life  Insurance  Co., 
1917.     78p. 

UNCLASSIFIED 

Armstrong,  D.  B.     Methods  of  investigation  in  social  and   health   problems;   necessity  of 
health  standards,  1917.     24p. 

Aronovici,  Carrol  Suggestions  for  social  surveys  of  small  towns  and  cities.     1913.     77p. 

Aronovici,  Carrol  The  social  survey.     1916.       255p.     Health  228-230,  bibliography. 

Bannington,  B.  G.  English  public  health  administration.     1915.     330p. 

Dublin,  L.  I.  The  application  of  the  statistical  method  to  public  health  research. 

Fisher,  Irving  National  vitality.     1910.     130p. 

Harrison,  S.  M.  Community  action  through  surveys.  Russell  Sage  Foundation,  Sep- 
tember 1916.     29p. 

Peabody,  S.  W.  Historical  study  of  legislation  regarding  public  health  in  the  states 
of  New  York  and  Massachusetts.  Journal  of  Infectious  Diseases, 
1909. 

Schneider,  Franz,  jr.     Some  shortcomings  of  socio-sanitary  investigations. 


Index 

By  Elizabeth  R.  Cummer 


Absenteeism  due  to  sickness,  541-42 

Accident  and  health  hazard,  construction 
trades,  535;  department  stores,  593; 
domestic  service,  603;  metal  trades, 
560;  printing,  592;  telephone  work, 
571,  594;  textile  and  knitting  mills, 
561 

Accident  incidence,  see  Industrial  acci- 
dent and  sickness  statistics 

Academy  of  Medicine,  136-37,  141,  214, 
401,  403,  413;  history  and  activities, 
664-65;  suggested  cooperation  with 
Dispensary  Committee,  899-900,  913 

Administrative  areas,  42,  46 

Agricultural  and  domestic  service,  for 
children,  602-3 

Ambulance  service,  in  industry,  533; 
necessity  for  adequate,  458;  no  pro- 
vision for  City  Infirmary,  964;  plan 
for  city-wide,  964;  present  facilities, 
961;  promptness,  961-62;  provisions 
in  other  cities,  961;  recommendations, 
964-65;    requisites  for  efficient,  962-63 

American  habit  of  mind  or  work,  from 
practical  to  theoretical,  25 

American  Medical  Association,  pamphlets 
on  nostrums  and  quackery,  677 

American  Society  for  Control  of  Cancer, 
program  for  prevention  and  cure, 
221-25 

Animal  Protective  League,  factor  in  con- 
trol of  rabies,  137;  provisions  for 
transportation  of  dogs,  963 

Anti-spitting  ordinance,  enforcement,  332, 
354 


Anti-Tuberculosis  League,  193;  activities, 
362 ;  development  of  educational  work 
in  industry,  363;  extension  of  pro- 
gram, 369;   follow-up  of  cases,  367 

Arsphenamine,  provision  by  state,  885 

Artificial  feeding,  see  Infant  care 

Associated  Charities,  activities,  196-97; 
cooperation  with  health  centers,  363; 
families  with  mental  disorders  under 
care  of,  498;  mental  test  registry,  500; 
psychological  approach  to  problems  of 
individuals,  497-98 

Association  for  the  Crippled  and  Disabled, 
193 ;  organization  and  functions,  204-6; 
responsibility  for  adequate  follow-up 
work,  208;  social  service,  204-5,  953. 
See  also  Care  of  cripples 

Association  for  Prevention  and  Relief  of 
Heart  Disease,  cooperation  in  prepar- 
ing program,  213 

Autopsies,  importance,  864;  number  in 
hospitals,  1919,  667,864;  percentage, 
668,865 

Autopsy,  use  not  appreciated,  667; 
means  for  increasing  use,  669 

Babies'  Dispensary,  building,  893;  clinic 
training  for  University  District  stu- 
dents, 751;  cooperation  with  Humane 
Society,  917-18;  extension  of  scope, 
897;  fees  and  finances,  894;  location, 
•  892;  medical  supervision  of  boarded- 
out  children,  177;  medical  work,  "895; 
organization,  892-93;  orthopedic  fa- 
cilities, 203;  patients,  893;  social 
service,  895-96,  953;  visits,  1919,  890. 
See  also  University  Hospital  Group 

Baby  prophylactic  stations,  826,  986.  See 
also  Health  Centers 


*The  subjects  listed  in  the  Index  are  given  for  the  report  as  a  whole  and  are  not  classified  by  the 
various  Parts.  The  pages  of  the  report  are  numbered  consecutively  throughout  the  eleven  Parts:  Part  I, 
1-96;  Part  II,  97-260;  Part  III,  261-324;  Part  IV,  325-388;  Part  V,  389-436;  Part  VI,  437-516;  Part 
VII,  517-644;    Part  VIII,  645-700;    Part  IX,  701  to  812;    Part  X,  813-996;    Part  XI,  997-1082. 


1062 


Hospital  and  Health  Survey 


Bar  Association,  Americanization  Com- 
mittee, 677 

Bathing  beach  waters,  pollution  by  sew- 
age, 62 

Belle vue  Hospital,  956 

Benjamin  Rose  Institute,  provision  of 
funds  for  cafe  of  crippled  children,  204 

Birth  registration,  check  of,  167;  in- 
adequacy of,  276-77;  method  of  secur- 
ing 100%,  278;  relative  number  of 
births  reported  by  midwives  and 
physicians,  277.  See  also  Bureau  of 
Vital  Statistics 

Births,  1919,  275-76 

Blindness,  see  Prevention  of  blindness; 
Board  of  Education,  special  classes; 
Society  for  Blind 

Board  of  Education,  cooperation  in  pre- 
vention of  heart  disease,  214,  218,  305; 
cooperation  with  Division  of  Health, 
272;  physical  training,  296-97,  312-13; 
provision  for  crippled  children,  206; 
provision  for  tuberculous  children,  362 ; 
psychological  clinic;  462,  486,  488;  sani- 
tary supervision,  297-301,  315-18; 
special  classes:  cardiac,  295;  for 
blind,  294;  for  cripples,  206,  294-95; 
for  deaf,  294;  for  mentally  defective, 
295,  488-90;  nutrition,  295;  open-air, 
293-94;  speech  defects,  295,  494-95 
See  also  Department  of  Medical  In- 
spection; Health  education 

Boarding  homes,  dental  work  for  children, 
178;  medical  supervision  of  children, 
177-78;  supervision,  178,  287,  762-63; 
suggested  procedure  for  placing-out  of 
children,  178-80 

Bodily  mechanics,  need  for  community 
education  in,  198 

Boston,     City     Hospital,     956;      hospital 

service  per  1,000  population,  830 
Boys'  School,  486 

Brace  shop,  present,  203;  proposed  cen- 
tral, 200-1 

Bratenahl  Village,  school  nursing  service, 
778 


Breast  feeding,  see  Infant  care 

Bureau  of  Child  Hygiene,  143;  activities, 
280-83.  See  also  Prenatal  care;  Ma- 
ternity care;    Infant  care 

Bureau  of  Communicable  Disease,  122-38; 
cards  used,  124-25;  Charter  provi- 
sions for,  122;  control  of  rabies,  137; 
culturing  in  diphtheria,  125;  disinfec- 
tion after  smallpox,  127;  disinfection 
of  library  books,  126;  duties  of  chief, 
122;  extension  of  scope,  122;  im- 
munization against  diphtheria,  126; 
need  for  skilled  intubator,  136;  per- 
sonnel, 122;  quarantine,  125,  137-38; 
regulations  of  Sanitary  Code,  123-24; 
reporting  by  physicians,  124;  results 
of  control  measures,  127;  supervision 
of  district  physicians,  140;  vaccination, 
126-27 

Bureau  of  Food  and  Dairy  Inspection, 
148-54,  357;  classification  of  milk 
dealers,  153;  control  of  communicable 
diseases  in  animals,  122;  control  of 
rabies,  149-50,  dairy  inspection,  151; 
defects  in  milk  control,  150-1;  organ- 
ization, 148;  appointment  of  person- 
nel, 154;  present  separation  of  food 
inspection  service,  154;  recommenda- 
tions for  milk  and  dairy  inspection, 
154;  summary  of  work  for  1919,  148- 
50;  supervision  of  slaughtering  and 
sale  of  meat,  150 

Bureau  of  Industrial  Hygiene,  need,  554; 
proposed  activity  for  Division  of 
Health,  185 

Bureau  of  Juvenile  Research,  see  State 
Bureau  of  Juvenile  Research 

Bureau  of  Laboratories,  155-61;  chief 
criticisms  of  bacteriological  laboratory, 
157;  duties  of  chief,  155;  functions, 
155-56;  inspection  work,  160-61;  main 
distributing  stations  for  outfits,  157-59; 
microscopic  and  serological  examina- 
tions for  venereal  diseases,  400;  milk 
examinations,  155-56;  organization, 
155;  patent  medicines,  161;  summary 
of  results  of  examination  of  city  water, 
1919,  15,9;  work  of  bacteriological  lab- 


Index 


1063 


oratory,  156-57;   work  of  chemical  lab- 
oratory, 160-61 

Bureau  of  Preventable  Diseases,  scope  of 
such  a  bureau,  122-23 

Bureau  of  Sanitation,  144-47,  357;  activi- 
ties, 144-45;  actual  work,  146-47; 
excuse  for  lodging  house  conditions, 
53;  indifference  to  enforcement  of 
tenement  ordinances,  48-49;  lack  of 
constructive  and  preventive  work, 
144,  145;  method  of  receiving  com- 
plaints, 144;  organization,  144;  re- 
sponsible for  abatement  of  nuisances 
relating  to  dumps,  74;  control  of  fly- 
breeding  places,  83;  study  of  field 
work,  145;  supervision  of  field  force, 
144;   tenement  house  code,  145-46 

Bureau  of  Tuberculosis,  closer  relations 
with  Medical  School,  369;  need  for 
full-time  chief,  368:  organization  and 
activities,  355-56 

Bureau  of  Vital  Statistics,  165-72;  ap- 
propriation, equipment  and  personnel, 
1 66 ;  cooperation  with  Bureau  of  Com- 
municable Disease,  168;  duties  of 
registrar,  168-69,  171;  three  elements  of 
a  reorganized  service,  167;  formulation 
of  new  system,  167-72;  inadequacy  of 
present  records,  165;  lack  of  enforce- 
ment of  birth  registration,  276-77; 
nature  of  data  for  tuberculosis,  357; 
need  for  improved  statistical  work, 
369;  need  for  intelligent  supervision, 
168;  present  ,methods  of  operation, 
166;   recommendations,  172 

Candy  factories,  employment  of  women, 
562;   employment  of  children,  590 

Cancer,  prevention  and  cure,  221-25 

Cardiac  disease,  see  Heart  disease 

Care  of  convalescents,  study  of  200  dis- 
charged hospital  cases,  927-37;  com- 
munity program  for,  938-43 

Care  of  cripples,  197-212;  funds  provided 
by  Benjamin  Rose  Institute,  204;  lack 
of  orthopedic  supervision  in  schools, 
197;     points    considered    in    problem, 


201:  present  needs,  207-8;  program, 
208-9;  recommendations,  209-12;  re- 
habilitation of  industrial  cripples,  198, 
547,  550;  vocational  therapy,  205; 
facilities:  brace-making,  203;  con- 
valescent, 203;  coordination  by  Asso- 
ciation for  Crippled  and  Disabled, 
204-6;  dispensary,  202-3;  educational, 
206;  hospital,  202,  832;  hydrotherapy, 
202;  physiotherapy,  202-3;  social 
service,  203-4 

Care  of  chronic  illness,  at  City  Infirmary, 
948-50;  lack  of  provision  for,  946-48; 
medical  service,  944;  need  for  institu- 
tion for,  945;  nursing  service,  944; 
problem  distinguished  from  that  of 
canvalescence,  945;  responsibility  of 
city,  946,  948;    summary,  951 

Care  of  sick,  factors  determining  choice  of 
resources,   820-21;    resources,   27,   820 

Census  tracts,  see  Sanitary  areas 

Central  Child  Hygiene  Council,  Commit- 
tee on  Infant  Care,  283;    Committee 
on  Maternity  Care,  278;    Committee 
on    Prenatal     Care,     274;      functions, 
•  270,  272;    membership,  270 

Central  Committee  on  Public  Health 
Nursing,  activities,  757;  composition 
and  activities,  112-13;  organization, 
756;  recommendations,  757-58;  sug- 
gested inclusion  of  industrial  nursing 
representative,  807;  plan  for  factory 
service,  777;  valuable  asset  to  public 
health  nursing,  756 

Central  downtown  dispensary,  estimated 
cost,  924;  financing,  923-24;  industri- 
al clinic  in  connection  with,  553;  initia- 
tive for  starting,  924-25;  needs  to  be 
met  by,  922;  suggested  connection 
with  orthopedic  center,  200;  sug- 
gested site  and  services,  923 

Chamber  of  Commerce,  housing  survey, 
353;  quotation  from  report  on 
Housing  Conditions  of  War  Workers, 
43;    smoke  prevention,  85 

Charity  Hospital,  see  St.  Vincent's  Char- 
ity 


1064 


Hospital  and  Health  Survey 


Child-caring  institutions,  licensing,  287; 
medical  survey,  287;  number  and 
capacity,  287;  number  planning  new 
buildings,  175;  objects  of  study  of, 
174-75;  problems  of  delinquency,  487; 
recommendations,  176-77,  287;  sani- 
tary survey,  287;  summary  of  medical 
service,  175-76 

Child  health  work,  four  great  features  of 
present  program,  268;  lack  of  pre- 
ventive health  functions,  267-68; 
measure  of  its  effectiveness,  319-20; 
need  of  central  control,  267-270;  pres- 
ent organization,  267-68;  proposed 
organization,  270  73;  recommenda- 
tions, 274-75,  278-80,  283-84,  285-87, 
287-88,  301-18;  summary  of  problem, 
269-70;  summary  of  report  on,  29-30; 
two  fundamental  bases,  268.  See  also 
Central  Child  Hygiene  Council;  Pre- 
natal care;  Maternity  care;  Infant 
care;   Pre-school  age  care 

Child  Labor  Laws,  age  and  educational 
requirements,  582-83;  enforcement, 
583,  585-86;  health  requirements,  583; 
reasons  for  evasion,  586-87;  reasons 
for  inadequate  enforcement,  586;  rem- 
edy for  lack  of  enforcement,  587;  spe- 
cial vacation  certificate,  583;  street 
trades,  583 

Childhood,  importance  of  adolescent 
period,  580 

Children  and  industry,  brief  outline  of 
study,  581;  education's  responsibility, 
613-18;  need  for  junior  vocational 
department,  596-97,  615;  reasons  for 
including  study  in  survey,  579;  recom- 
mendations, 619-21;  summary  of  re- 
port, 31-32;  three  general  considera- 
tions involved  in  health  study,  579-80 
statistics:  sources  of  information, 
583-84;  number  of  children  at  work, 
584;  ages  and  number  of  children  ap- 
plying for  work,  585;  occupations 
employing  children,  588 
See  also  Occupations  employing  chil- 
dren; Street  trades;  Agricultural 
work  and  domestic  service;  Child 
Labor  Laws 


Children's  Fresh  Air  Camp,  dental  serv- 
ice, 687;  preventorium  advantages, 
361;    provisions  for  convalescents,  941 

Children's  Placement  Bureau,  proposed 
new  activity  for  the  Division  of  Health, 
178-80 

Chronic  cases,  classification,  947-48 

City  Charter,  provisions,  106-9;  suggested 
changes,  119,  654,  839-40 

City  Farm,  description,  465 

City  Hospital,  admission  procedure  for 
tuberculosis  cases,  356;  ambulance 
service,  961 ;  approval  of  bond  issue 
for,  458,  966;  charter  changes  sug- 
gested, 654,  839-40;  deficiency  of 
nursing  service,  838;  number  of  beds, 
828;  out-patient  department  needed, 
918;  plans  for  expansion,  966;  pro- 
posed psychopathic  department  and 
"outposts",  458,  462,  479,  481,  486; 
social  service,  953,  955;  study  of  con- 
valescent cases  from,  930-32;  sug- 
gested plan  for  a  venereal  disease 
service,  410; 

facilities:  contagious  cases,  832; 
dental  surgery,  684-85,  687;  mental 
cases,  446-47,  458;  tuberculosis  cases, 
360;    venereal  diseases,  402,  410,  832 

training  school  for  nurses:  organiza- 
tion, 714;  minimum  entrance  require- 
ments, 715-16;  capacity  of  hospital 
and  services  offered,  717-18,  724;  in- 
struction in  nursing  procedures,  724- 
27;  instruction  in'  sciences,  728-32; 
instruction  in  other  subjects,  732-35; 
ratio  of  nurses  to  patients,  735;  day 
duty,  736;  night  duty,  737-38;  vaca- 
tion, 738;    living  conditions,  740-41 

City  Infirmary,  insufficient  service,  839, 
949;  location  and  capacity,  948;  per- 
sonnel, 948;  provision  for  mental 
cases,  465.-66;  utilization  for  chronic 
cases,  949 

City  Plan  Commission,  48,  353 

Climate,  46-47 

Clinics,  cardiac,  215,  219,  897;  dental, 
293,    684-86,    903-4;     industiial     553, 


Index 


1065 


923;  need  for  psychiatric,  462,  479, 
481,  486;  prenatal,  274,  826,  902-3, 
986;  psychological,  462,  486,  488; 
venereal  disease,  401,  404,  885.  See 
a!so  Dispensaries 

College  of  Dentistry,  see  Dental  School 

Commissioner  of  Health,  appointment, 
111;  part-time  office,  111;  powers 
and  duties,  109 

Commissioner  of  Publicity  and  Research, 
duties,  108;  reasons  why  position 
should  be  filled,  110 

Commissioner  of  Smoke  Prevention,  88-89 

Committee  for  Prevention  and  Relief  of 
Heart  Disease,  214 

Committee  for  vice  investigations,  426-27 

Committee  on  Nursing  Education,  studies 
of  hospital  training  schools,  712 

Community,  attitude  toward  hospitals 
and  dispensaries,  820-21;  complaints 
regarding  provisions  for  mental  cases, 
444-45;  interest  of,  576-77;  planning 
of  hospitals  and  dispensaries,  966-72; 
spirit,  377,  983-84;  supervision  of 
mentally  defective,  495-96 

Construction  trades,  accident  and  health 
hazards,  535-36;  accident  incidence, 
542 

Consultation  service,  establishment  of,  366 

Consumers'  League,  campaign  for  en- 
forcement of  street  trades  ordinance, 
598 ;  cooperation  in  study  of  Children 
and  Industry,  581;  investigation  of 
milk  situation,  347;  program  for  in- 
creasing use  of  milk,  352 

Consumption,  see  Tuberculosis 

Contagious  diseases,  estimated  number  of 
hospital  beds  needed,  832 

Control  of  drug  addiction,  new  activity 
proposed  for  Division  of  Health,  189-90 

Control  of  tuberculosis,  see  Tuberculosis 

Control  of  venereal  diseases,  see  Venereal 
diseases 


Convalescence,  two  things  apparent  in 
study,  926-27;  problem  of,  938:  in- 
stitution needed  for  some  cases,  938-39; 
methods  of  dealing  with  problem,  940- 
41 

Coroner  system,  recommendations,  191 

Correctional  agencies,  482-87 

Cost  accounting,  in  hospitals,  870-71,  877- 
79 

County  commissioners,  872 

County  jail,  provision  for  mental  cases, 
464-65 

Courts,  476-82;  relation  to  problem  of 
mental  diseases,  476 

Cripple  School,  206,  294-95 

Day  nursiiies;  admission  procedure,  181- 
82;  attendance,  181,  285;  discussion 
of  social  worth,  574-75;  licensing,  181; 
medical  service,  182-83;  number,  180- 
81,  285;  ordinances  regulating,  181; 
recommendations,  184-85;  summary 
of  conditions  found,  184;  supervision 
of,  181 

Dental  hygienists,  licensing,  810;  train- 
ing and  legalization,  689 

Dental  Research  Laboratory,  689 

Dental  School,  graduate  education,  689; 
present  needs,  688-89;  public  dental 
clinic,  685 ;  work  for  boarded-out 
chifdren,  178 

Dental  service,  dispensary  facilities,  293, 
684-86;  inadequacy,  686;  in  hospitals, 
686-88;  in  industry,  545,  688;  in 
schools,  293,  684,  685;  need  for  pay 
clinics,  685;  need  for  supervision  in 
dispensary,  686;  surgical,  684-85, 
685-86 

Dental  Society,  689 

Dentistry,  Ohio  Dental  Practice  Act,  683 ; 
private  practice  of,  683-84;  recom- 
mendations, 690;  summary  of  report, 
32;  two  movements  important  in  ad- 
vancing, 683 


1066 


Hospital  and  Health  Survey 


Dentists,     education, 
registered,  683 


5-89;      number 


Department  of  Buildings,  responsible  for 
school  sanitation,  297-301;  recom- 
mendations, 315-18 

Department  of  Health,  see  Division  of 
Health 

Department  of  Medical  Inspection,  clin- 
ical facilities,  293;  conferences,  295; 
correction  of  physical  defects,  290-92; 
examination  for  and  issuance  of  work 
permits,  605-7;  examination  of  teach- 
ers, 297;  health  records,  295-96; 
medical  personnel,  289-90;  organiza- 
tion, 289;  school  dispensaries,  295; 
supervision  of  control  of  communi- 
cable diseases,  296;  recommendations, 
302-15 

nursing  service:  analysis  of  activi- 
ties, 783-86;  conferences,  788;  duties, 
290-92;  field  nurses,  292-93,  786-87; 
junior  health  workers,  293,  787;  scope 
of  work,  782-83;  staff,  783;  staff 
nurses,  787;    supervisor,  786 

Department  of  Physical  Training,  activi- 
ties, 296-97;   recommendations,  312-13 

Department  of  Public  Welfare,  Charter 
provisions   for,    108-9;     divisions,    110 

Detention  Home,  481-82,  484 

Detention  Hospital,  476 

Diphtheria,  reasons  for  high  death  rate, 
136-37  « 

Director  of  Public  Service,  plans  for 
changes  in  organization,  81;  respon- 
sible for  cleanliness  of  city,  67 

Director  of  Public  Welfare,  general  powers 
and  duties,  108;    appointment,  111 

Dispensaries,  adaptation  of  clinics  to 
clientele,  914;  administration,  915; 
admission  of  patients,  912;  buildings, 
893;  classes  of  disease  treated,  892; 
classification,  826,  890;  clinic  manage- 
ment, 899;  deficiencies,  897;  fees  and 
finances,  894,  913-14;  for  mental 
diseases,  462;  in  industry,  533,  536; 
in  schools,  295,  311-12;    location,  890, 


892;  inter-relations,  915;  means  of  ad- 
mission to  hospital  wards,  852;  means 
of  providing  after-care  for  hospital 
patients,  856;  medical  organization, 
846;  medical  relations,  899-900,  913; 
medical  work  and  records,  895;  need 
for  general  plan,  919-21;  need  for  en- 
largement of  service,  862-63;  needed 
improvements  in  service,  918;  organ- 
ization and  executive  control,  892-93; 
patients,  893;  public  health,  901-2, 
986;  relation  to  hospitals,  897,  899; 
reports  and  tests  of  service,  896-97; 
shortage  of  service,  912;  social  serv- 
ice, 895-96;  supervision,  417-18.  See 
also  Central  downtown  dispensary; 
Clinics;  Health  centers;  Hospitals 
and  dispensaries 

Dispensary,  definition  of  term,  826 

District  physicians,  duties,  139;  method 
of  receiving  calls,  139;  offices,  139; 
organization,  138-39;  recommenda- 
tions, 141-42;  records,  140;  summary 
of  complaints  of  service,  141 ;  super- 
vision, 140;    volume  of  work,  140 

Division  of  Health,  administrative  dis- 
tricts, 114-16;  appointment  of  per- 
sonnel, 111,  112-13;  appropriation  for 
1920,  113;  board  or  advisory  com- 
mission lacking,  110;  bureaus,  112; 
conferences,  116;  cooperation  with 
Board  of  Education  in  child  health 
matters,  272;  educational  campaign 
for  control  of  venereal  disease,  410-11; 
filing,  119;  hours  of  service,  111;  legal 
action,  119;  library,  116-19;  morale, 
121;  need  for  full-time  executive,  ill; 
number  of  employes,  114;  organiza- 
tion, 355-57f;  per  capita  cost  1884- 
1920,  113-14;  per  capita  cost  com- 
pared with  Detroit's,  114;  rules  for 
regulation  of  laboratories,  416-17; 
Sanitary  Code,  119;  services  not 
offered,  112;  supervision  of  dispen- 
saries, 417-18;    supply  system,  111 

activities  proposed:  173,  214;  con- 
trol of  drug  addiction,  189-90;  exten- 
sion district,  769;  industrial  hygiene, 
185;    institutional  inspection,    173-85; 


Index 


1067 


licensing  of  child-caring  institutions, 
287;  medical  examination  for  city 
employes,  185-86;  public  health  edu- 
cation, 186-89;  supervision  of  board- 
ing-out homes,  287;  Venereal  Disease 
Bureau,  413-14 

nursing  service:  appointments  of 
field  nurses,  112-13;  chronic  illness, 
944;  communicable  diseases,  759-60; 
child  hygiene,  281-83,  761-62;  instruc- 
tion of  new  nurses,  768;  midwife 
supervision,  277,  762;  organization, 
764;  proposed  extension  district,  769, 
803;  parochial  schools,  763;  prenatal, 
763-64;  prevention  of  blindness,  762; 
recommendations,  769-73;  scope  of 
work,  758-59;  staff,  759,  764,  767-68; 
summary,  768-69;  supervision  of 
boarding  homes,  762-63;  tuberculosis, 
356-57,  760-61;  uniforms,  768 
See  also  Bureau  of  Child  Hygiene; 
Bureau  of  Communicable  Diseases; 
Bureau  of  Food  and  Dairy  Inspection ; 
Bureau  of  Laboratories;  Bureau  of 
Sanitation;  Bureau  of  Tuberculosis; 
Bureau  of  Vital  Statistics;  Health 
centers 

Division  of  Police,  ambulance  service, 
961;  modern  conception  of  functions, 
426;  proposed  Women's  Bureau,  424- 
26;  test  of  efficiency  in  controlling 
vice  conditions,  427-28 

Downtown  dispensary,  see  Central  down- 
town dispensary 

Draft  boards,  figures  for  venereal  disease, 
398;      findings  of    medical   examiners, 

541-42 

Education  and  practice  in  medicine,  sum- 
mary of  report,  32 

Endemic  Index,  127 

Epileptics,  laws  relating  to,  469;  state 
hospital  for,  473 

Extension  district,  769,  803 

Fairview  Park  Hospital,  number  of  beds, 
828;  out-patient  department,  919; 
provisions  for  mental  cases,  461 ; 


training  school  for  nurses:  organiza- 
tion, 714;  minimum  entrance  require- 
ments, 715-16;  capacity  of  hospital 
and  services  offered,  723;  teaching  of 
nursing  procedures,  724-27;  teaching 
of  fundamental  sciences,  728-32;  in- 
struction in  other  subjects,  732-35 
ratio  of  nurses  to  patients,  735-36 
day  duty,  736;  night  duty,  737-38 
vacation,  738;  living  conditions,  740- 
41 

Farm  School,  484 

Federal  Bureau  of  Labor  Statistics,  540 

Federal  Census  Bureau,  census  units  or 
sanitary  areas,  42 

Federal  Children's  Bureau,  summary  of 
standards  of  physical  fitness  for  work- 
ing children,  611-13 

Federal  Fraud  Order  Law,  scope  and  limita- 
tions, 676;  suggested  means  for  more 
aggressive  use,  677 

Feeble-minded,  see  Mentally  defective 

Feeding  of  infants,  see  Infant  care 

First   aid,    training   necessary   for    ambu- 
lance crews,  962 
Flies,  83-84 

Foreign-language  press,  advertisements  of 
quacks,  672-75;  income  from  quack 
and  patent  medicine  advertisements, 
678;  opportunities  for  Americaniza- 
tion of  immigrant,  678;  patent  medi- 
cine advertisements,  675 

Garbage  collection  and  disposal,  67-73, 
75,  80-82 

Garment  trades,  earnings  of  employes, 
562;  number  of  women  employed, 
561;  regularization  of  employment, 
561-62;    type  of  women  in,   562 

General  environment  and  sanitation, 
summary  of  report,  28 

Generalized  public  health  nursing,  115; 
definition,  281,  334,  366-67,  754;  dis- 
cussion, 357,  754;'  need  for  change  in 
organization,  distribution  and  super- 
vision of  nurses'  work,    283;    need  for 


1068 


Hospital  and  Health  Survey 


specialized  supervision,  367;  neglect 
of  infant  hygiene  work  under,  282-83; 
prenatal  and  postnatal  work,  801-2; 
standard  ratio  of  nurses  to  population, 
375,  755;  success  of  system,  754; 
prime  requisite  of,  755;  some  causes 
of  failure,  755-56;  used  in  University 
public  health  nursing  course,  746 

Girls'  Home,  484-85 

Glenville  Hospital,  number  of  beds,  828; 
training  school  for  nurses:  organiza- 
tion, 714;  minimum  entrance  require- 
ments, 715-16;  capacity  of  hospital 
and  services  offered,  723,  "724;  teach- 
ing of  nursing  procedures,  724-27; 
teaching  of  fundamental  sciences,  728- 
32;  instruction  in  other  subjects,  732- 
35;  day  duty,  736;  night  duty,  737-38; 
vacation,  738;  living  conditions,  740- 
41 

Goiter,  detection  and  abatement,  291-92; 
endemic,  46 

Gonorrhea,  see  Venereal  diseases   ■ 

Government  Diagnostic  Clinic,  400-1 

Grace  Hospital,  number  of  beds,  828 

Griswold  Act,  authorization  of  institu- 
tional inspection,  173;  reference  to, 
124 

Health  administration  surveys,  aims  and 
methods,  1009-17;  factors  determining 
scope,  1007-8;  history  of,  1005-7; 
preliminary  steps,  1004-5;  reasons  for 
making,  1003 

Health  centers,  administrative  work,  908; 
case  classification,  343-44;  dental 
work,  684;  description,  115;  districts, 
114;  extension,  283-84,  971;  facilities 
for  tuberculosis  work,  355;  financial 
administration,  909-10;  infant  welfare 
work,  280-83,  761-62;  location  and 
clinics,  904-5,  986;  medical  work,  280- 
81,  907-8;  method  of  referring  babies 
to,  282;  nursing  service,  765-66;  pa- 
tients, 905-6;  personnel,  907;  pre- 
ventive rather  than  curative,  826; 
provision   of  milk   by,   906-7;     really 


branch  offices,  115;  reasons  for  de- 
crease in  number  of  new  tuberculosis 
cases,  344;  records,  119,  767,  908-9; 
recommendations,  190,  910-11;  social 
work,  908;  supervision  of  children  of 
pre-school  age,  285-86;  supplementary 
equipment  needed,  366;  tuberculosis 
attendance,  344;  tuberculosis  nursing, 
356-57,  760-61 

Health  Department,  see  Division  of  Health 

Health  districts,  location  of  hospitals,  835; 
proposed  use  of  one  as  extension  dis- 
trict, 769;  facilities  for  prevention  and 
treatment  of  sick,  116;  statistics  for 
report  based  on,  42 

Health  education,  anti-tuberculosis,  346, 
363,  368;  function  of  a  downtown  dis- 
pensary, 922;  importance  in  training 
for  industrial  life,  614-15;  important 
part  of  industrial  nursing,  805-6;  in 
industry,  363;  in  the  public  schools, 
297;  means  of  combating  quackery 
and  patent  medicines,  677;  for  pre- 
vention of  heart  disease,  218;  recom- 
mendations, 189,  313-14;  resume  of 
present  services,  186-89;  under  Divi- 
sion of  Health,  108,  110,  112,  188; 
views  of  International  Red  Cross  in 
regard  to,  188-89;  weapon  against 
disease  and  disability,  26-27.  See  also 
Sex  education ;   Mental  hygiene 

Health  hazards,  see  Accident  and  health 
hazards 

Health  services,  recommendations,  226-28; 
summary  of  report,  28-29 

Health  supervision  in  industry,  see  Medi- 
cal service  in  industry 

Health  supervision  in  schools,  see  School 
health  supervision 

Health  supervision  of  children  at  work, 
medical  examination  for  work  permit, 
603-7;  suggested  content  of  Ohio  law 
re  health  certificate,  607;  subnormal 
children,  608-10;  summary  of  stand- 
ards of  normal  development  and  physi- 
cal fitness,  611-13. 
See  also  Work  permits 


Index 

Heart  disease,  prevention  and  relief,  213- 
21 

Holy  Cross  House,  facilities  for  care  of 
non-pulmonary  tuberculosis,  361;  pro- 
visions for  convalescents,  941 

Home  conditions  of  working  people,  rela- 
tion to  health,  557 

Home  work,  a  method  used  by  factories  to 
increase  output,  573;  advantages  in 
special  cases,  574;    various  kinds,  573 

Hospital  beds,  for  children,  831-32;  for 
contagious  diseases,  832;  for  eye,  ear, 
nose  and  throat  cases,  831;  for  ob- 
stetrical cases,  275,  831;  for  orthopedic 
cases,  202,  832;  for  tuberculosis,  361- 
62,  366;  for  venereal  diseases,  402, 
832;  shortage,  832-33,  836;  total 
number  available,  828-29;  utilization, 
833-35,  836 

Hospital     census,     economic     status      of 
patient    according    to    nativity,     851 
length  of  stay  of  patients,   844,    946 
location  of  residence  of  patients,  829 
nativity  of  patients,    850;    percentage 
of   bed    occupancy,     833;     sources    of 
admission    of   patients,     852-53,     858; 
type  of  service,  831-32 

Hospital  Council,  193,  214;  activities, 
872,  981-82;  membership  in,  981,  983; 
number  of  beds  in  hospitals  of,  828; 
opportunities  for  service,  982;  pro- 
posed Dispensary  Section,  406,  920-21, 
982;  Purchasing  Bureau,  874-75,  882- 
84;  recommended  interest  in  increase 
of  post-mortem  examinations,  671; 
report  forms,  974;  suggested  coopera- 
tion with  Academy  of  Medicine,  899- 
900 

Hospital  hygiene,  milk  supply,  888-89; 
ventilation,  889;   water  supply,  889 

Hospital  statistics,  autopsies,  667-68, 
864-65;  compilation  thro  a  central 
office,  169-71;  number  of  beds  per 
1,000  population,  829;  service  per 
1,000  population  in  other  cities,  830. 
See  also  Hospital  census 


1069 

Hospital  survey,  in  northern  England, 
1007 

Hospital  training  schools,  capacity  of  hos- 
pitals and  services  offered,  716-24; 
conditions  of  work,  735-38;  cost  ac- 
counting, 714;  extent  of  study,  709; 
general  characteristics,  709;  instruc- 
tion, 724-35;  living  conditions,  740-41; 
minimum  entrance  requirements,  715- 
16;  money  allowance  to  students,  714; 
organization,  713-14,  842;  provision 
of  ward  helpers,  738-40;  recommenda- 
tions, 742-45 

Hospitals,  assistance  in  home  conva- 
lescence, 936-37;  attitude  toward  non- 
staff  physicians,  858-60;  authority  of 
superintendent,  843;  autopsies  per- 
formed in  1919,  864-65;  days  of  care, 
833;  deficient  in  provision  for  special 
classes  of  cases,  83 1 ;  democratization 
of  facilities,  862-63;  difficulty  in  secur- . 
ing  admission  for  venereal  disease 
cases,  402;  distribution,  835,  837; 
facilities  for  mental  cases,  446-47,  458- 
62;  basis  of  organization,  838-40; 
principles  of  organization,  845-48;  pre- 
dominantly devoted  to  surgery,  831; 
planning  of  policy,  973;  rate  for  in- 
dustrial cases,  872;  reimbursement  by 
county  or  city  for  public  charges, 
872-74;  reports,  973-77;  services  of  pub- 
licity expert  needed,  977-78;  shortage 
of  beds,  830-31;  social  service  depart- 
ment, 843,  855; 

administration:  economics  and  sal- 
vaging, 886-87;  financial,  869-71, 
877-82;  general  recommendations, 
887-888;    purchasing,   874-75,    882-86; 

board  of  trustees:  breadth  of  vision 
needed,  978;  complete  authority  of, 
841;  composition,  840,  841-42;  duties, 
843-45,  871; 

classification:  by  diseases  treated, 
822;  by  relation  to  community,  822, 
824;  by  quality  of  service,  824-26; 
by  range  of  service,  835-36; 

medical  staffs:  foreign-born  physi- 
cians, 863;  functions,  861;  member- 
ship, 664,  858,  860;  necessity  for,  861; 


1070 


Hospital  and  Health  Survey 


negro    physicians,     863;     organization, 
846-47,  862,  865-67; 

relation  to  community:  admission 
procedure,  852;  giving  information 
about  patients,  851-52;  problem  of 
the  foreign-born  patient,  850-51,  853- 
54;  problem  of  after-care,  854-56; 
cooperation  with  charitable  organiza- 
tions, 852-53;  cooperation  with  in- 
dustrial establishments,  -853 ;  financial 
support  dependent  upon,  857;  human 
problem  of  the  patient,  849-50;  serv- 
ice for  middle  classes,  871-72 
See  also  Detention  Hospital;  Indus- 
trial hospitals;  State  Hospital  for  In- 
sane 

Hospitals  and  dispensaries,  attitude  of 
community  toward,  820-21;  classifica- 
tion of,  822;  cost  of  maintenance, 
868-69;  educational  function,  863-65; 
method  of  approach  to  study  of,  820; 
primary  purpose,  819;  problem  of  in- 
terpreting to  community,  827;  sum- 
mary of  report  on,  33-34;  unit  for 
measurement  of  service,  826-27; 

planning  by  community:  971-72; 
building  fund  campaign,  966-67;  ex- 
tension of  health  centers,  971;  loca- 
tions and  re-locations,  969-70;  pro- 
jected enlargements,  967-68;  special 
services  needed,  968-69; 

social  service  departments:  coopera- 
tion with  charitable  agencies,  956-57; 
development,  952;  functions,  954, 
958,  959-60;  importance  of  person- 
ality and  training  of  head  worker, 
957-58;  lack  of  definite  policy,  953-54; 
organization,  843,  848,  957;  recom- 
mendation, 955 

Hotels,  earnings  of  women  employes,  570; 
present  method  of  employment,  570; 
supervision  of,  570 

House  of  Correction,  482-84 
House  of  Good  Shepherd,  485-86 

Housing,  advantages  of  zoning,  48;  char- 
acteristics of  residential  districts,  42, 
43;  conditions  in  lodging  houses,  53- 
55;     conditions    in    tenements,     48-49, 


53;  legislation,  346-47;  proximity  of 
home  to  industry,  43;  recommenda- 
tions, 55-56;  records  of  Division  of 
Buildings,  353-54;  results  of  over- 
crowding, 48;  survey  by  Chamber  of 
Commerce,  48,  353;  violation  of  ordi- 
nances, 53 

Housing  Conditions  of  War  Workers,  quo- 
tation from  report  by  Chamber  of 
Commerce  and  U.  S.  Home  Registra- 
tion Service,  43 

Humane  Society,  child  placement  work, 
178;  intelligence  tests,  499;  medical 
supervision  of  boarded-out  children, 
916-18 

Huron  Road  Hospital,  number  of  beds, 
828;    plans  for  expansion,  967; 

dispensary:  building,  893;  classes 
of  disease  treated,  892;  deficiencies, 
897;  fees  and  finances,  894;  location, 
890;  medical  work,  895;  organiza- 
tion, 892;  records,  895;  visits,  1919, 
890 

training  school  for  nurses:   organiza- 
tion, 714;    minimum  entrance  require- 
ments,   715-16;     capacity    of  hospital 
and  services  offered,    723-24;    teaching 
of  nursing  procedures,  724-27;     teach- 
ing  of  fundamental   sciences,     728-32 
instruction  in  other  subjects,    732-35 
ratio    of   nurses    to    patients,    735-36 
day    duty,    736;     night    duty,    737-38 
vacation,     738;      provision     of    ward 
helpers,     738-40;      living     conditions, 
740-41 

Hydrotherapy,  202 


Industrial  accident  and  sickness  statistics, 
analysis  of  reportable  accidents,  540; 
computation  of  frequency  and  severity 
rates,  540;  importance,  539;  investi- 
gation of  absenteeism  due  to  sickness 
and  non-industrial  accidents,  541-42; 
tabulation  of,  540;  time  loss  in  small 
■  industrial  establishments,  550-51 

Industrial  clinic,   advantages  of   associat- 
ing    with     department     of     industrial 


Index 


1071 


hygiene,  553;  proposed  in  connection 
with  central  dispensary,  553,  923 

Industrial  cripples,  198,  547,  550 
Industrial  dental  service,  545,  688 

Industrial  establishments,  number  and 
size,  525-26; 

employing  women:  558-59;  acci- 
dent and  health  hazards,  560,  561; 
benefits,  564-65;   earnings  of  employes, 

561,  562,  564;  hours  of  work,  561, 
563;  nature  of  women's  work,  560; 
number  of  women  employes,  559,   561, 

562,  563;  physical  conditions  of  work, 
567-68;  physical  examinations,  560; 
regularization  of  employment,  561-62; 
supervision,  562,  565-66;  type  of 
worker,  561,  562,  563;  uniforms,  560 
See  also  Medical  service  in  industry; 
Small  industrial  establishments 

Industrial  health  supervision,  see  Medical 
service  in  industry 

Industrial  hospitals,  552 

Industrial  hygiene  survey,  purpose  and 
methods,  525 

Industrial  medical  records,  forms  used, 
538-39;  lack  of  essential  data,  537; 
standards  for,  537-38;  value  in  pre- 
paring accurate  reports  and  tables, 
539 

Industrial  nurses,  administration  of  medi- 
cation by,  530;  contribution  to  in- 
dustrial hygiene,  529-30;  home  visit- 
ing by,  531;  need  for  counsel  and 
technical  assistance,  531;  number,  803; 
some  causes  of  failure,  806-7;  training, 
529,553;  type  of  service,  804-6;  used 
for  absence  follow-up,  531-32 

Industrial  Nurses'  Club,  value  of,  531 

Industrial  ocular  service,  importance, 
545-46;   need  for  eye  hospital,  546 

Industrial  physicians,  in  advisability  of 
combining  official  and  personal  prac- 
tice among  employes,  528;  special 
training,  553;    types,   527 

Industrial  psychiatry,  value,  544-45 


Industrial  unrest,  544-45 

Industrial  visiting  nursing,  531,  777 

Industry,  its  interest  in  health  of  employes, 
557,  558 

Infant  care,  carried  on  thro  14  health 
centers,  280,  761-62;  committee  on, 
283;  field  not  covered  by  health  cen- 
ters, 281;  "generalized"  '[nursing  un- 
fortunate type  in,  281;  great  value  of 
home  visiting  by  nurses,  282-83;  im- 
portance of  breast  feeding,  282;  meas- 
ure of  its  effectiveness,  319;  need 
for  agency  to  supply  wet  nurses,  283; 
number  of  children  in  need  of,  281; 
recommendations,  283-84;  too  great 
emphasis  placed  on  artificial  feeding, 
282.  See  also  Bureau  of  Child  Hy- 
giene;   Health  Centers 

Infant  mortality,  reduction  in,  273,  282 

Institute  of  School  Hygiene,  752 

Institutional  deliveries,  in  1919,  275-76 

Institutional  inspection,  proposed  activity 
for  Division  of  Health,  173,  287 

Institutions,  study  of,  174-85 

International  Red  Cross,  views  in  regard 
to  health  education,  188-89.  See  also, 
Red  Cross 

Insanity,  see  Mental  diseases  and  de- 
ficiency 

Jewish  Orphan  Asylum,  dental  service,  687 

Juvenile  Court,  Detention  Home,   481-82 
management     of     delinquency,      480 
method   of  disposal   of  cases,    480-81 
need  for  psychiatric  clinic,  481;  sources 
of  information  regarding  cases,  480 

Laboratories  supervision,  400,  416-417. 
See  also  Bureau  of  Laboratories 

Lakeside  Hospital,  dental  service,  688; 
number  of  beds,  828;  orthopedic  facili- 
ties, 202;  provisions  for  mental  cases, 
460-61;  social  service  department,  952; 
study  of  convalescent  cases,  932-34; 


1072 


Hospital  and  Health  Survey 


dispensary:  building,  893;  classes 
of  disease  treated,  892;  deficiencies, 
897;  fees  and  finances,  894;  location, 
890;  medical  work,  895;  future  plans, 
919;  organization,  892;  orthopedic 
facilities,  202;  patients,  893;  proposed 
psychiatric  clinic,  461;  records,  895; 
venereal  disease  clinic,  401,  406-7; 
visits,  1919,  890; 

training  school  for  nurses:  organi- 
zation, 714;  minimum  entrance  re- 
quirements, 715-16;  capacity  of  hos- 
pital and  services  offered,  718-24; 
teaching  of  nursing  procedures,  724-27, 
728;  teaching  of  fundamental  sciences, 
728-32;  instruction  in  other  subjects, 
732-35;  ratio  of  nurses  to  patients, 
735-36;  day  duty,  736;  night  duty, 
737-38;  vacation,  738;  living  condi- 
tions, 740-41 
See  also  University  Hospital  Group 

Lakewood  Hospital,  number  of  beds,  828; 
provisions  for  mental  cases,  461; 

training  school  for  nurses:     organi- 
zation,   714;     minimum    entrance    re- 
quirements,  715-16;    capacity  of   hos- 
pital and  services  offered,  723 ;  teaching 
of  nursing  procedures,   724-27;    teach- 
ing  of  fundamental   sciences,    728-32 
instruction  in  other  subjects,    732-35 
day  duty,     736;     night  duty,    737-38 
vacation,  738;    living  conditions,    740- 
41 

Lakewood  Visiting  Nurse  Association, 
affiliation,  778 

Laundries,  earnings  of  employes,  570;  ob- 
jectional  features  of  work,  569 ;  scarcity 
of  female  labor  in,  569;  working  hours, 
570 

Legislation,  anti  -  tuberculosis,  346-47; 
housing,  346-47;  milk,  346;  relating 
to  Bureau  of  Juvenile  Research,  473- 
74;  relating  to  insane,  468-69;  re- 
lating to  mentally  defective  and  epi- 
leptic, 469;  sex  delinquency,  419-24. 
See  also  Child  Labor  Laws;  Pharmacy 
Laws 

Lutheran  Hospital,  number  of  beds,  828; 
plans  for  expansion,  968 


Manufacture  of  hosiery  and  knit  goods, 
employment  of  children,  590-91; 

Massachusetts  General  Hospital,  ortho- 
pedic social  service,  199 

Maternity  care,  committee  on,  278;  hos- 
pital facilities,.  275,  279,  831;  measure 
of  its  effectiveness,  319;  out-patient 
service,  276;  recommendations,  278- 
80.  See  also  Prenatal  and  maternity 
nursing  service 

Maternity  Center  Association  of  New 
York  City,  accomplishments,  274 

Maternity  Hospital,  number  of  beds,  828; 
nursing  service,  '799-801;  prenatal 
clinics,  902-3; 

training  school  for   nurses:    instruc- 
tion,   727-28;    day   duty,    736;    night 
duty,  737-38;    vacation,  738 
See  also  University  Hospital  Group 

Maternal  mortality,  see  Mortality  sta- 
tistics 

"Medical  boarding  house",  services  offered 
by,  825 

Medical  education,  see  School  of  Medicine 

Medical  examination,  see  Physical  exami- 
nations 

Medical  Journal,  666 

Medical  Library  Association,  history  and 
activities,  665-66 

Medical  practice,  institutional,  822.  See 
also  Physicians 

Medical  School,  see  School  of  Medicine 

Medical  service  in  industry,  administra- 
tive relations,  534-35;  ambulance  serv- 
ice, 533;  beyond  the  plant,  536-37; 
clerical  personnel,  532;  cost  of  service, 
533-34;  dispensary  equipment,  533; 
needed  in  small  establishments,  .550; 
number  of  firms  offering,  526;  oppor- 
tunities for  health  education,  547; 
physical  examinations,  542-44;  present 
inadequacy,  363;  purpose  and  methods 


Index 


1073 


of  survey,  525;  quality,  526;  recom- 
mendations, 554-56;  special  services, 
544-47;  summary  of  report  on,  31. 
See  also  Industrial  medical  records;  In- 
dustrial nurses;  Industrial  physicians; 
Small  industrial  establishments 

Medical  service  in  non-industrial  estab- 
lishments, 535-36 

Medical  service  in  schools,  see  School 
health  supervision 

Medical  social  service,  895-96;  assistance 
in  cases  of  chronic  illness,  947;  for 
cardiac  patients,  218-19;  at  City 
Hospitals  elsewhere,  956;  City  Hos- 
pital, 953,  955;  cooperation  with 
charitable  agencies,  956-57;  develop- 
ment, 952;  functions,  954,  958,  959-60; 
•  lack  of  definite  policy,  953-54;  Lake- 
side Hospital,  952;  for  orthopedic 
cases,  203-6,  207;  Mt.  Sinai  Hospital, 
952;  needed  for  convalescent  care,  930, 
932;  problems,  954-55;  recommenda- 
tion, 955;  St.  Vincent's,  952,  953; 
value  in  orthopedic  departments,  199 

Medical  staff  appointments,  see  Hospitals 

Medico-social  service,  contribution  to 
study  of,  25 

Mental  diseases,  need  for  local  society  for 
prevention  of,  225 

Mental  diseases  and  deficiency,  com- 
plaints in  regard  to  provisions  for,  444- 
45;  methods  of  dealing  with  problems 
presented,  443;  part  played  in  prob- 
lems of  social  agencies,  497;  preven- 
tion, 501-2;  recommendations,  503-11; 
scope  of  survey,  444;  summary  of  re- 
port on,  31; 

city  facilities  for  care:  dispensaries, 
462;  hospitals,  446-47,  458-62;  infirm- 
ary, 465-66;  jail,  464-65;  private 
sanitaria,  462-64 

state  facilities  for  care:  Board  of 
Administration,  467-68;  Bureau  of 
Juvenile  Research,  473-75;  Hospital 
for  Epileptics,  473;  hospitals  for  in- 
sane, 469-71 ;  Institution  for  Feeble- 
minded, 471-73;    laws,  468-69 


See  also  Courts ;  Correctional  agencies ; 
Red  Cross;  Associated  Charities; 
Humane  Society;  Women's  Protec- 
tive Association 

Mental  hygiene,  501-2 

Mental  medicine,  facilities  for  teaching 
460-61;  lack  of  attention  given  to 
problem  of,  460 

Mentally  atypical  children,  in  schools, 
488-96 

Mentally  defective,  estimated  number  in 
state  and  city,  471-72 ;  laws  relating  to, 
469;  need  for  supervision,  472,  495-96; 
need  for  increased  institutional  pro- 
vision, 472;  special  classes,  488-90; 
state  institution  for,  471;  two  out- 
standing needs  in  care  of,  473;  work 
permits,  490-93 

Mercantile  establishments,  earnings  of  em- 
ployes, 568,  569;  educational  depart- 
ments, 568;  employment  of  children, 
592-93;  health  departments,  568; 
hours  of  work,  568;  number  of  women 
employed,  568 

Metal  trades,  accident  hazard,  560;  acci- 
dent incidence,  542;  employment  of 
boys,  591;  number  of  children  em- 
ployed, 591; 

women  employes:  earnings,  561; 
hours  of  work,  561;  nature  of  [work, 
560;  number,  559;  physical  examina- 
tion, 560;    type,  561;    uniforms,  560 

Midwifery,  comparison  of  courses  in,  277 

Midwifery  control,  evils  of  present  system, 
277-78;    suggested  program,  279-80 

Midwives,  inadequate  supervision,  277; 
number,'277;  social  need  filled  by,  277; 
stringency  of  regulations  for  licensing, 
277;    supervision,  762 

Milk,  dietary  and  nutritional  value,  348, 
351-52;  results  from  study  of  its  con- 
sumption, 348-51;  the  problem  in 
Cleveland,  347.   See  also  Legislation 


1074 


Hospital  and  Health  Survey 


Milk  supply,  control,  148-49,  150-51;  in 
hospitals,  888-89;  reasons  for  unsatis- 
factory condition,  154;  results  of  bac- 
teriological examinations  in  March  and 
June,  1920,  151-53 

Modern  hospital,  services  offered,  825 

Morbidity  statistics',  compilation,  169; 
contagious  diseases  of  children,  284- 
85;  ratio  of  active  tuberculosis  cases 
to  deaths,  345;  reporting  of  tuber- 
culosis, 343, 345;  venereal  diseases,  398 

Mortality  statistics,  general  death  rates, 
1910-19,  city,  338;  heart  disease  death 
rate  for  state  and  city,  213;  leading 
causes  of  death  in  city  and  state,  339; 
maternal,  274 

tuberculosis:  at  Division  of  Health, 
357;  distribution  of  deaths  by  age,  sex, 
occupation  and  form,  342-43;  death 
rates,  1865-1911,,  339;  residence  factor 
in  figures,  343 

Mosquitoes,  83-84 

Mothers'  pensions,  inadequacy,  575 

Mount  Sinai  Hospital,  number  of  beds, 
828;  orthopedic  facilities,  202;  pro- 
visions for  mental  cases,  461 ;  social 
service  departments,  952;  study  of 
convalescent  cases,  934-35; 

dispensary:  building,  893;  classes  of 
disease  treated,  892 ;  deficiencies,  897; 
dental  clinic,  686-87;  fees  and  finances, 
894;  location,  890;  medical  work  and 
records,  895;  organization,  892;  ortho- 
pedic facilities,  202;  patients,  893; 
social  service,  895-96;  venereal  disease 
clinic,  401,  408; 

training  school  for  nurses:  organi- 
zation, 714;  minimum  entrance  re- 
quirements, 715-16;  capacity  of  hos- 
pital and  services  offered,  718-24; 
teaching  of  nursing  procedure,  724-27, 
728;  teaching  of  fundamental  sciences, 
728-32;  instruction  in  other  subjects, 
732-35;  ratio  of  nurses  to  patients, 
735-36;  day  duty,  736;  night  duty, 
737-38;     vacation,    738;     provision    of 


ward    helpers,    738-40;     living    condi- 
tions, 740-41 

Mouth  hygiene,  need,  686;    value,  685 

Mouth  Hygiene  Association,  activities, 
689;  clinics  at  Health  Centers,  684, 
903-4;  extension  of  dental  service 
needed,  685 

Municipal  Court,  need  for  psychiatric 
clinic,  478-79;  Parole  Board,  479-80; 
work  of  Probation  Officer,  479 


New  York  City,  hospital  service  per  1000 
population,  830 

New  York  State,  provisions  for  licensing 
and  inspecting  private  institutions  for 
mental  cases,  463 

Night  work,  its  problem,  571-73 

Northern  Ohio  Druggists'  Association,  co- 
operation with  Division  of  Health,  694 

Nursing,  summary  of  report,  32-33.  See 
also  Nursing  education;  Public  health 
nursing;    Private  duty  nursing 

Nursing  education,  recommendations,  741- 
45 ;  standards  of  comparison  for  study, 
709-10;  study  by  Committee  on  Nurs- 
ing Education,  712.  See  also  Univer- 
sity School  of  Nursing;  Hospital 
training  schools;  University  course  in 
public  health  nursing;  Institute  of 
School  Hygiene 

Nutrition  classes,  295,  362 


Occupations  employing  children,  588-89; 
comments  of  employers,  596;  educa- 
tional requirements,  595-96;  functions 
of  medical  service,  591;  health  haz- 
ards, 592,  593-94,  596-97;  hours  of 
work,  589;  nature  of  work  and  oppor- 
tunity for  advancement,  590-95;  wages, 
589 

Ophthalmia  neonatorum,  see  Prevention  of 
blindness 

Open-air  classes,  293-94,  362 


I  X  D  E  X 


1075 


Orthopedic  center,  association  with  down- 
town clinic,  200,  923;  central  brace 
shop,  200-1;  main  physiotherapeutic 
plant,   200;    organization,  208-9. 

Orthopedic  Council,  responsibility  for  all 
medical  and  social  follow-up  work,  208 

Orthopedic  organization,  functions  and 
essentials  for  fulfillment,  198-99 

Orthopedic  surgery,  at  Medical  School, 
197,  201-2,  207-8;  convalescent  beds 
needed,  199-200;  hospital  beds,  832; 
departments  in  general  hospitals,  199; 
field,  197-98;  functional  rehabilitation 
of  injured  wage-earners,  198;  need  for 
children's  service,  199;  number  of 
specialists,  197,  663;  possibilities,  197; 
value  of  social  service  in  clinics,  199 

Outdoor  Relief  Department,  admission 
routine  for  Infirmary,  949 

Out-patient  departments,  see  Dispensaries 

Parochial  schools,  dental  service,  685; 
medical  inspection,  288,  301;  nursing 
service,  763 

Patent  medicines,  advertisement,  675; 
capital  invested  in  manufacture  and 
sale,  161-62;  cooperation  of  druggists 
and  City  Chemist  regarding,  694; 
distribution  and  sale,  162-63;  manu- 
facture, 162;  need  for  classification, 
162;  recommendations,  164,  682; 
local  situation,  163-64 

Per  capita  per  diem  cost,  in  hospitals, 
869-70,  878-79 

Pharmacists,  indispensable  auxiliaries  to 
physicians,  691;  number  registered, 
691 

Pharmacy,  recommendations,  697-98; 
summary  of  report,  32 

Pharmacy  laws,  691-94 

Physical  defects,  correction,  290-92,  784- 
85;  emphasis  on  prevention,  308;  in- 
cidence in  school  children  by  age 
periods  and  sex,  304 


Physical  examinations,  for  hospital  per- 
sonnel, 888;  in  industry,  542-44;  for 
city  employes,  185-86,  544;  for  oper- 
ators of  conveyances,  544;  for  food- 
handlers,  543.  See  also  School  health 
supervision 

Physiotherapy,  care  provided  by  Associa- 
tion for  Crippled  and  Disabled,  206; 
main  and  branch  plants,  200;  present 
facilities,  202-3,  207 

Physicians,  diagnostic  training  for,  366; 
foreign-born,  863;  hospital  staff  ap- 
pointments, 664,  858,  860;  negro, 
863;  number  and  classification  by 
specialty,  663;  professional  oppor- 
tunities, 664,  666-67;  professional  or- 
ganization, 664-66 

Pilgrim  Church,  nursing  service,  777-78 

Playgrounds,  streets  used  as,  67 

Police  Department,  see  Division  of  Police 

"Police  Emergency",  method  of  sending 
in  calls,  961 ;  provisions  for  ambulance 
service,  962-63;  stigma  attached  to 
use  of,  963-64;  used  as  ambulance,  961 

Population,  history  of  city's  growth',  39 

Population  statistics,  age  and  race  distri- 
bution, 41 ;  city  and  county  subdivi- 
sions, 1918,  44-45;  city  and  suburbs, 
1900-18,  41-42;    density,  42-43 

Post-mortem  examination,  see  Autopsies 

Prenatal  and  maternity  nursing  service, 
902-3;  present  facilities,  797;  types  of 
cases  in  need  of,  797-98;  types  of  care 
needed,  798;  agencies  considered  for 
city-wide,  798-803;  recommendations, 
803 

Prenatal  care,  clinics,  274,  826,  902-3, 
986;  committee  on,  274;  measure  of 
effectiveness,  319;  need  for  increase 
of  facilities,  274;  number  of  mothers 
provided  for  in  1919,  273;  object,  273; 
plan  for  city-wide  service,  274-75; 
797-803,     902-3;      present    provisions, 


1076 


Hospital  and  Health  Survey 


273;  recommendations,  274-75;  re- 
duction in  death  rate  from  puerperal 
sepsis,  274;  reduction  in  infant  mor- 
tality, 273;  reduction  in  stillbirth 
rate,  274.  See  also,  University  District; 
Division  of  Health,  nursing  service; 
Visiting  Nurse  Association 

Pre-school  age  care,  gap  in  child  health 
program,  285;  lack  of  facilities,  285; 
measure  of  its  effectiveness,  319;  need 
for,  284-85;    recommendations,  285-87 

Prevention  of  blindness,  793;  activity  of 
Division  of  Health,  762 ;  program  pre- 
pared by  the  national  committee, 
195-96;  results  from  follow-up  of 
ophthalmia  neonatorum  cases,  278 

Prevention  of  disease,  devices  for,  26-27 

Printing  and  publishing,  employment  of 
children,  592 

Private  duty  nursing,  study  of  unneces- 
sary employment  of  full-time  graduate 
nurses,  808-9;  employment  of  trained 
attendants,  809-10 

Probate  Court,  cost  of  committing  mental 
cases,  477-78;  function  in  regard  to 
mental  cases,  476;  method  of  com- 
mitment of  mental  cases,  476-77 

Provident  Hospital,  number  of  beds,  828 

Psychiatric  clinics,  in  general  hospitals, 
461-62;  needed  in  connection  with 
courts,  479,  481,  486;  proposed  uni- 
versity, 461,  462;    of  Red  Cross,  497 

Psychiatry,  definition  of,  545.  See  also, 
Industrial   psychiatry;     Mental   medi- 


Psychological  clinic,  462,  486,  488 

Psychology,'  definition  of,  544-45 

Psychopathic  hospitals,  see  City  Hospital; 
State  Psychopathic  Hospitals 

Public  Health  Association,  980;  recom- 
mendation for  creation,  104;  section 
on  Child  Hygiene,  270 


Public  health  education,  see  Health  educa- 
tion 

Public  health  nurses,  present  number  in- 
adequate, 366 

Public  health  nursing,  elements  of  success, 
753,  754;  scope  of  survey,  753. 
See  also  Division  of  Health;  Depart- 
ment of  Medical  Inspection;  Visiting 
Nurse  Association;  University  Dis- 
trict; Industrial  nurses;  Generalized 
public  health  nursing;  Central  Com- 
mittee on  Public  Health  Nursing; 
Pre-natal  and  Maternity  service;  Uni- 
versity course  in  public  health  nursing 

Public  health  organization,  additional 
non-official  agencies  needed,  212;  im- 
portance, 25;  official  and  non-official, 
103 

Public  service  organizations,  employing 
women,  569-71 

Public  utilities,  employing  women,  571 

Pure  Food  Law,  provisions  of,  675 

Quacks,  dental,  683-84; 

medical:  peril  to  immigrant,  672; 
advertisements  in  foreign-language 
newspapers,  672-73,  679-82;  expert 
psychologists,  678;  methods  of  evad- 
ing the  law,  673;  methods  of  appeal, 
674-75;  instrument  for  detection  of, 
676;    recommendations,  682 


Rabies,  control,  137;    149-50 

Rainbow  Hospital,  convalescent  care, 
203,  941;  enlargement  of  scope  of 
work  suggested,  942;  facilities  for 
care  of  non-pulmonary  tuberculosis, 
361;  limited  in  field  of  action,  207; 
number  of  beds,  828 

Rapid  Transit  Company,  quotation  from 
report,  43 

Recommendations,  55-56,  59,  66,  81-82, 
83-84,  90,  104,  141-42,  164,  172,  176- 
77,  184-85,  189,  190,  191,  209-12,  219- 


Index 

20,  226-28,  274-75,  278-80,  283-84, 
285-87,  287-88,  301-18,  334-35,  370-76, 
401,  403-4,  404,  406,  407-8,  409,  412, 
421-22,  503-11,  554-56,  575-76,  619-21, 
669-71,  682,  690,  697-98,  741-45,  751- 
52,  757-58,  769-73,  781-82,  788-89, 
796-97,  803,  887-88,  910-11,  917,  964- 
65;    summary,  35-38 

Recreation,  employment  of  a  director,  429; 
importance  in  venereal  disease  cam- 
paign, 395,  429;  suggested  improve- 
ment of  facilities,  396 

Red  Cross,  health  education,  314,  363; 
neuro-psychiatric  clinic,  497.  See  also 
International  Red  Cross 

Restaurants,  earnings  and  hours  of  work 
of  waitresses,  571 

Rubbish  and  ashes,  73-75,  80-81;  recom- 
mendations, 81-82 

St.  Alexis  Hospital,  number  of  beds,  828; 
orthopedic  facilities,  202,  203;  out- 
patient department  needed,  918-19; 

training  school  for  nurses:  organiza- 
tion, 714;  minimum  entrance  require- 
ments, 715-16;  capacity  of  hospital 
and  services  offered,  718-23;  teaching 
727;  day  duty,  736;  night  duty,  737- 
38;  vacation,  738;  living  conditions, 
740-41 

St.  Ann's  Maternity  Hospital,  number  of 
beds,  828; 

training  school  for  nurses:  teaching 
of  nursing  procedures,  727-28;  day 
duty,  736;  night  duty,  737-38;  vaca- 
tion, 738; 

St.  Clair  Hospital,  number  of  beds,  828 

St.  John's  Hospital,  number  of  beds,  828; 
orthopedic  facilities,  202;  out-patient 
department  needed,  918;  provisions 
for  mental  cases,  461; 

training  school  for  nurses:  organiza- 
tion, 714;  minimum  entrance  require- 
ments, 715-16;  capacity  of  hospital 
and  services  offered,  718-23;  teaching 
of  nursing  procedure,  724-27;   teaching 


1077 

of  fundamental   sciences,    728-32;    in- 
struction   in    other    subjects,    732-35 
ratio    of   nurses    to    patients,    735-36 
day   duty,    736;     night   duty,    737-38 
vacation,  738;    living  conditions,  740- 
41 

St.  Luke's  Hospital,  dental  service,  687; 
number  of  beds,  828;  orthopedic  facili- 
ties,\202;    plans  for  expansion,  967; 

dispensary:  building,  893;  classes 
of  disease  treated,  892;  deficiencies, 
897;  fees  and  finances,  894;  future 
plans,  919;  location,  892;  medical 
work  and  records,  895;  organization, 
892;  patients,  893;  social  service, 
895-96;    visits,  1919,  890; 

training  school  for  nurses:  organiza- 
tion, 714;  minimum  entrance  require- 
ments, 715-16;  capacity  of  hospital 
and  services  offered,  718-24;  teaching 
of  nursing  procedures,  724-28;  teaching 
of  fundamental  sciences,  728-32;  in- 
struction in  other  subjects,  732-35 
ratio  of  nurses  to  patients,  735-36 
day  duty,  736;  night  duty,  737-38 
vacation,  738;  living  conditions,  740-41 

St.    Vincent's    Charity    Hospital,    dental 
service,    688;     number    of  beds,    828 
social  ^service    department,    952,    953 
study  of  convalescent   cases,    928-30 

dispensary:  building,  893;  classes 
of  disease  treated,  892;  deficiencies, 
897;'  fees  and  finances,  894;  location, 
890 ;v medical  work  and  records,  895; 
organization,  892;  orthopedic  facili- 
ties, 202;  patients,  893;  social  service, 
895-96;  venereal  disease  clinic,  401, 
408,  409;  .visits,  1919,  890; 

training  school  for  nurses:   organiza- 
tion, 714;    minimum  entrance  require- 
ments,   715-16;     capacity   of  hospital 
and  services  offered,  718-23;   teaching 
of  nursing  procedure,  724-27;  teaching 
of  fundamental  sciences,   728-32;    in- 
struction   in    other    subjects,    732-35 
ratio    of   nurses    to    patients,    735-36 
day   duty,    736;    night   duty,    737-38 
vacation,  738;    living  conditions,  740 
41 


1078 


Hospital  and  Health  Survey 


Sanitaria,  for  mental  cases,  462-64 

Sanitary  areas,  definition,  42;  number,  46; 
reasons  for  adoption,  114-15 

Sanitary  Code,  119;  authority  for  control 
of  acute  communicable  disease,  122; 
regulations  in  regard  to  communicable 
diseases,  123-24;  suggested  section 
about  laboratory  and  dispensary  super- 
vision, 416-18i 

Sanitary  Index,  127 

Sanitation,  see  Collection  and  disposal  of 
garbage;  Collection  of  rubbish  and 
refuse;  Flies;  Housing;  Mosquitoes; 
Smoke;   Water  supply;   Milk  supply 

Schick  test,  used  in  institutions,  126 

School  attendance   department,   583,    586 

School  doctors,  see  Department  of  Medical 
Inspection 

School  for  deaf,  294 

School  health  supervision,  measure  of  its 
effectiveness,  319;  parochial  schools, 
288,  301,  763;  private  schools,  301; 
recommendations,  301-18; 

public  schools:  health  education, 
297;  lack  of  coordination  of  different 
types  of  health  work,  301-2;  medical 
inspections,  288-96;  physical  training, 
296-97,  312-13;  sanitary  supervision, 
297-301;    nursing  service,  782-88 

School  hygiene,  see  Department  of  Build- 
ings 

School  nursing,  see  Department  of  Medical 
Inspection 

School  of  Medicine,  community  relations, 
655-56;  curriculum  and  instruction, 
656-59;  Dean,  659;  deficient  recogni- 
tion of  many  specialties,  651;  depart- 
mental distribution  of  teaching  staff, 
660;  distribution  of  graduates,  660-61; 
educational  vJue  of  hospital  and  dis- 
pensary, 863-65;  facilities  for  clinical 
teaching,  653;  faculty  organization, 
657-58;    graduates  on  hospital  staffs, 


860;  history,  659;  hours  of  work  re- 
quired, 660;  inadequacy  of  educa- 
tional facilities  in  orthopedics,  207-8; 
lack  of  recognition  of  orthopedics,  197; 
post-graduate  instruction,  662;  facili- 
ties for  teaching  mental  medicine, 
460-61 ;  problems  of  construction  and 
endowment,  653-55;  proposed  depart- 
ment of  industrial  hygiene,  553,  656; 
recommendations,  669-71;  statistics, 
661-62;  suggested  activities  in  re- 
search and  teaching,  368 

School  of  Pharmacy,  faculty,  695; 
finances,  695;  history,  694-95;  hos- 
pital service  offered  by,  696-97,  875- 
76,  885;  needs,  695-96;  standard,  697 

Sewage  disposal,  60-66;  recommendations, 
66 

Sex  delinquency,  institutional  care  of 
offenders,  430;  laws  and  machinery 
for  enforcement,  419-27;  preventive 
work,  429;  probation  work,  425,  429; 
protective  work,  425,  429-30 

Sex  education,  method  for  control  of 
venereal  disease,  396;  for  children, 
431-32;  for  young  men  and  women, 
432;  permanent  measures  for,  432-33; 
social  hygiene  information  for  parents 
and  leaders  of  public  opinion,  432 

Shortage  of  labor,  reasons,  559 

Sickness,  cost,  26;  relation  to  dependency, 
26;  three  services  necessary  for  care 
and  prevention,  26;    studies  of,  819 

Sickness  incidence,  see  Industrial  accident 
and  sickness  statistics 

Small  industrial  establishments,  550-51 

Smallpox,  problem,  126-27 

Smoke,  effect  of  air  pollution  on  health, 
88;  effect  on  climate,  47;  necessity 
for  prevention,  85;  present  expendi- 
tures for  prevention,  89;  present  or- 
ganization for  prevention,  88-89;  rec- 
ommendations, 90;  soot-fall  studies, 
85-87 


Index 


1079 


Smoke  investigation  of  Pittsburgh,  quota- 
tion from  Bulletin  S,  85 

Social  hygiene,  see  Venereal  diseases;  Sex 
education 

Social  service,  see  Medical  social  service 

Social  Service  Clearing  House,  functions, 
958-59;  suggested  extension  of  scope, 
935;    use,  959 

Society  for  the  Blind,  193-95 

Soot-fall  studies,  analyses,  86-87;  appa- 
ratus used,  86;  extent,  86;  purpose  of, 
86 

State  Board  of  Administration,  direction 
of  care  of  insane,  467-68 

State  Board  of  Pharmacy;  lack  of  in- 
spectors, 693 

State  Bureau  of  Juvenile  Research,  473- 

74 

State  Dental  Practice  Act,  need  for 
amendment,  683 

State  Department  of  Health,  registration 
of  hospitals  and  dispensaries,  822; 
suggested  extension  of  supervisory 
powers,  979-80 

State  Fire  Marshal,  control  over  sanitaria, 
463 ;  responsible  for  health  among  food 
handlers,  544,  570 

State  Hospital  for  Epileptics,  473 

State  Hospital  for  Insane,  dental  service, 
688;  description,  470-71;  facilities  for 
care  of  tuberculosis  cases,  360 

State  Industrial  Commission,  analysis  of 
reportable  accidents,  540,  550;  Depart- 
ment of  Factory  Inspection,  583,  586, 
587;  hospital  rates  for  accident  cases 
872;  powers  to  safeguard  health  and 
safety  of  working-people,  553;  statis- 
tics for  eye  injuries,  546 

State  Institution  for  Feeble  -  minded, 
capacity,  471 


State  Medical  Board,  detection  of  quacks, 
676 

State  Psychopathic  Hospitals,  description 
of  one  located  in  city,  470-71;  need  for 
second  in  city,  470;  number,  469-70. 
See  also  State  Hospital  for  Insane 

State  Sanatorium,  360 

Statistics,  health  districts  used  as  basis 
in  report,  42;  list  of  statistical  tables, 
19-20;  list  of  graphs,  21-22;  wastage 
from  sickness  and  premature  death, 
25-26.  See  also  Children  and  industry; 
Federal  Eureau  of  Labor  Statistics; 
Hospital  statistics;  Industrial  acci- 
dent and  sickness  statistics;  Popula- 
tion statistics;    Vital  statistics 

Statistical    analysis,  importance,  338 

Street  cleaning,  78-82 

Street  trades,  extent  and  general  charac- 
ter of  newsboy  trade,  599-601;  ordi- 
nance, 597-98;  reasons  for  non- 
enforcement  of  ordinance,  598;  recom- 
mendations, 601-2;  undesirable  nature 
of  wcrk  for  children,  598-99 

Surveys,  child  health,  1006;  industrial 
hygiene,  1006;  mental  hygiene,  1006; 
Pittsburgh,  1006;  sickness,  1006; 
social,  1006;  Springfield  (Illinois), 
1006;  I  tuberculosis,  1006.  See  also 
Health  administration  surveys 

Syphilis,  see  Venereal  diseases 


Telegraph  work,  employment  of  children, 
595;   number  of  women  employed,  571 

Telephone  work,  employment  of  giris 
under  18,  593;  earnings,  571;  health 
hazard,  571,  594;  hours  of  work,  571; 
scarcity  of  operators,  571 

Textile  and  knitting  mills,  health  and 
accident  hazards,  561;  number  of 
women  employed,  561 


1080 


Hospital  and  Health  Survey 


Tobacco  factories,  difficulty  of  learning 
trade,  563;  number  of  women  em- 
ployed, 563 

Topography,  46 

Tuberculosis,  detection,  365-66;  equip- 
ment for  control,  331,  346;  expert 
consultation  service  needed  in  indus- 
try, 547;  follow-up  of  cases,  367;  im- 
mediate needs  for  prevention  and 
control,  332-34;  importance  of  ma- 
terial relief  in  treatment,  367;  impor- 
tance of  nursing  in  treatment,  366; 
institutional  care,  357,  360-62;  means 
of  prevention,  364-65;  past  accom- 
plishments in  control,  331-32;  preva- 
lence in  industry,  546;  recommenda- 
tions, 334-35,  370-76;  research  and 
teaching,  368;  summary  of  report,  30; 
treatment,  366-67;  work  at  health 
centers,  344,  355.  See  also  Health  edu- 
cation; Legislation;  Morbidity  sta- 
tistics;   Mortality  statistics 

Tuberculosis  nursing,  356-57;  366-67; 
760-61;    775;    791-92 

Tuberculosis  survey,  methods,  336-37; 
primary  objects,  336 

Undertakers,  ambulance  service,  961 

United  States  Home  Registration  Service, 
quotation  from  report  on  Housing 
Conditions  of  War  Workers,  43 

United  States  Marine  Hospital,  provisions 
for  mental  cases,  461-62 

United  States  Public  Health  Service,  ac- 
tivity in  combating  venereal  diseases, 
547 

University  course  in  public  heal th'nur sing, 
field  work,  748-51;  finances,  746;  in- 
struction, 748;  measure  of  success 
achieved  by,  751;  organization,  745- 
46;  origin,  745;  staff,  746-47;  stu- 
dents, 747-48 ^recommendations.  751- 
52 


University  District,  a  community  service, 
789-90;  description,  115-16;  factor  in 
success  of  public  health  nursing  course, 
746;  plan  of  administration,  790;  prac- 
tice field  for  public  health  nursing 
course,  745;  recommendations,  796-97; 
results  of  prenatal  care  in,  273,  274; 
staff,  790;  summary  of  work,  795-96; 
supervision,  795;  supervision  of  work 
of  students  in  University  course,  747, 
749-50; 

activities:  visiting  nursing,  790-91; 
child  hygiene,  791;  tuberculosis,  791- 
92;  communicable  disease  control, 
793;  prevention  of  blindness,  793; 
supervision  of  boarding  homes,  793; 
prenatal  nursing,  793-94;  school  nurs- 
ing, 794;    clinics,  794-95,  902-3 

University  Hospital  Group,  967;  order  of 
precedence  in  erection,  654-55 

University  psychiatric  clinic,  461,  462 

University  School  of  Nursing,  a  shorter 
basic  training  for  nurses,  712;  im- 
portant contribution  to  solution  of 
problem  of  nursing  education,  710; 
recommendations,  741-42;  some  bene- 
fits, 710-11;    special    function,    711-12 


Vaccination,  126-27 

Venereal  diseases,  diagnosis,  400-1;  draft 
board  figures  for,  398;  follow-up  of 
treatment,  414-16;  hospital  beds  for 
care  of,  401-2,  410,  832;  method  of 
combating  in  industry,  547;  preva- 
lence, 398-99;  prevention,  411-12; 
recommendations,  401,  403-4,  406, 
407-8,  409,  412,  421-22;  summary  of 
report,  30;  treatment  by  private 
physicians,  402-3;  treatment  in  dis- 
pensaries, 401,  404,  406-9; 

control:  campaign  for,  410-11; 
methods,  396-97,  429-30;  needs,  225, 
395-96;  past  accomplishments,  395; 
present  facilities,  395 
See  also,  Sex  delinquency,  Sex  educa- 
tion;  Recreation 


Index 


1081 


Venereal  Disease  Bureau,  proposed  or- 
ganization, 413-14 

Ventilation,  in  hospitals,  889;  in  schools, 
298 

Vice  conditions,  investigation,  427-28 

Vice  investigation,  proposed  committee 
for,  426-27 

Visiting  Nurse  Association,  193,  214;  ad- 
ministration, 778-81;  agency  for  city- 
wide  prenatal  service,  802-3;  care  of 
chronic  illness,  944;  experience  with 
trained  attendant  service,  810;  pres- 
ent equipment,  774;  recommendations, 
781-2;  scope  of  work,  773-74;  sug- 
gested annual  classification  of  patients, 
945; 

activities:  care  of  sick,  774-76; 
prenatal  nursing,  776;  maternity  serv- 
ice, 776-77;  industrial  nursing,  777; 
out-patient  maternity  affiliation,  777; 
Pilgrim  Church  service,  777-78;  serv- 
ice outside  city,  778 

Vital  statistics,  definition,  165;  state  law 
regarding,  167;  suggestion  for  institu- 
tion of  a  system,  167-72.  See  also 
Birth  registration,  Morbidity  statistics; 
Mortality  statistics 

Vocational  guidance,  advantage  of  bu- 
reaus connected  with  schools,  616; 
development  in  England  and  the 
United  States,  615;  need,  596-97; 
outline  for  department,  617-19 

Vocational  therapy,  facilities,  205 

Vocational  training,  614 


Warrensville  Children's  Camp,  361 

Warrensville  Tuberculosis  Sanatorium, 
case  bookkeeping,  368;  living  condi- 
tions, 367:  location  and  equipment, 
357,  360;  method  of  admission,  366; 
number  of  beds,  361,  828;  per  cent  of 
cases  leaving,  367-68 


Water  supply,  57-59;  in  hospitals,  889; 
recommendations.  59;  summary  of 
results  of  examination  of  city  water, 
1919,  159 

Welfare  Federation,  197,  499;  appropria- 
tion of  money  to  dispensaries,  920; 
establishment  of  expert  accountant 
service,  870-71;  functions,  980-81; 
history,  104-6;  present  equipment  for 
public  health  service,  104;  proposed 
organization  for  health  service,  104; 
publicity  service,  876,  978 

Western  Reserve  University,  education 
subject  to  three  main  limitations,  651; 
feeling"  of  public  for,  652;  lack  of  in- 
struction in  bodily  mechanics,  198; 
material  resources  for  teaching  and 
research,  652;  only  local  institution 
preparing  physicians,  dentists  and 
pharmacists,  651;  trustees,  652.  .See 
alsom  University  School  of  Nursing 

Wet"  nurses,  see  Infant  care 

Wholesale  and  retail  trade,  see  Mercantile 
establishments 

Woman's   Court,   424-25;     establishment, 

427 

Woman's  Hospital,  number  of  beds,  828 

Woman's  Police  Bureau,  424-25;  func- 
tions, 429 

Women's  Protective  Association,  425,  429; 
need  for  facilities  for  mental  examina- 
tions, 499;  social  investigations  for 
Probate  Court,  476 

Women's  work,  method  of  surveying,  558 

Women  and  industry,  day  nurseries,  574- 
75;  home  work,  573-74;  mothers' 
pensions,  575;  night  work,  571-73; 
recommendations,  575-76;  summary 
of  report,  31.  See  also,  Industrial  es- 
tablishments; Mercantile  establish- 
ments; Public  service  organizations; 
Public  utilities 


1082 


Hospital  and  Health  Survey 


Work  permits,  examination  made  by  De- 
partment of  Medical  Inspectio  n,  605-6 ; 
Federal  Children's  Bureau  health 
standards  for  children  entering  in- 
dustry, 603-4;  information  as  to 
mental  deficiencies,  608-9;  issuance 
by  Department  of  Medical  Inspection , 
606-7;  for  the  mentally  defective, 
490-93 


Working  environment  of  women,  reasons 
for  safeguarding,  557 

Workmen's  Compensation  Act,  543 

Year  Book,  suggested  publication,  171 

Zone,  definition  of  term  as  used  in  Child 
Health  report,  272 

Zoning  ordinance,  advantages,  48 


THE  CLEVELAND  HOSPITAL  AND  HEALTH  SURVEY 

REPORT 

List  of  Parts  and  Titles 

I.     Introduction. 

General  Environment. 
Sanitation. 

II.     Public  Health  Services. 
Private  Health  Agencies. 

III.  A  Program  for  Child  Health. 

IV.  Tuberculosis. 

V.     Venereal  Disease. 

VI.     Mental  Diseases  and  Mental  Deficiency. 

VII.     Industrial  Medical  Service. 
Women  and  Industry. 
Children  and  Industry. 

VEIL     Education  and  Practice  in  Medicine,  Dentistry,  Pharmacy. 

IX.     Nursing. 

X.     Hospitals  and  Dispensaries. 

XL     Method  of  Survey. 

Bibliography  of  Surveys. 
Index. 

The  complete  set  may  be  obtained  at  a  cost  of  $5.50  plus  the 
postage  and  single  parts  at  50  cents  each  plus  the  postage,  from 

THE  CLEVELAND  HOSPITAL  COUNCIL, 

308  Anisfield  Building, 
Cleveland,  Ohio 


Printed  by 

The  Pbemieb  Pbess 

Cleveland,  O. 


